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Hibrarp 


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7 


Deep  ami  superficial  flexors 

Space  lying  hettceen  bone 
arul  flex.  prof,  muscle 


Prolongation  of  ulnar  bursa 
under  flexor  prof,  muscle'"^^ 


Ant.  annular  lig 


Palmar  fascia 

Palmar  arch  and 
digital  nerve  \ 


'  Pronator  quadratus  m. 
Ulnar  bursa 


Dorsal  sheet  of  ulnar  bursa 
im,pinging  on  joint 

Interosseous  mus. 


Tendons  to  little  finger  in 
synovial  sheath 

.  Cut  head  of  fifth  metatarsal 


Drawing  Showing  Extension  of  the  Ulnar  Bursa  Underneath 
Dorsal  Surface  of  the  Flexor  Tendons  and  Space  into  which  Pus 
Ruptures  into  Forearm. 


INIECTIONS  OF  THI:  HAND 


A  GUIDE  TO  THE  SURGICAL  TREATMENT  OF 

ACUTE  AND  CHRONIC  SUPPURATIVE 

PROCESSES  IN  THE  FINGERS, 

HAND,  AND  FOREARM 


BY 


ALLEN  B.  KANAVEL,  M.D. 

ASSISTANT   PROFESSOR   OF   SURGERY,    NORTHWESTERN   UNIVERSITY   MEDICAL   SCHOOL; 
ATTENDING   SURGEON,    WESLEY   AND   COOK  COUNTY   HOSPITALS,   CHICAGO 


FOURTH  EDITION,  THOROUGHLY  REVISED 


flllugtrateD  witb  185  Engravinflg 


LEA    &    FEBIGER 

PHILADELPHIA    AND    NEW  YORK 
1921 


Copyright 

LEA  &  FEBIGER. 

1921 


1?  D  -S  ^  \ 


^X\ 


PREFACE  TO  FOURTH  EDITION. 


The  present  revision  has  given  the' author  the  oppor- 
tunity of  supplementing  the  text  with  the  knowledge 
gained  during  the  great  war  upon  gas  bacillus  and  strepto- 
coccus infections  as  well  as  permitting  the  addition  of  a 
chapter  upon  the  restoration  of  function  in  infected  hands. 

The  sequence  of  subjects  has  not  been  altered.  Begin- 
ning with  the  experimental  and  anatomical  studies  upon 
which  our  deductions  are  founded,  an  attempt  is  made  to 
give  the  reader  a  clear  understanding  of  the  basis  for 
proper  surgical  procedures.  While  dogmatic  statements 
as  to  the  proper  sites  for  incisions  might  be  made,  yet 
they  could  hold  true  only  for  the  usual  case,  and  it  is 
only  by  a  proper  appreciation  of  the  underlying  patho- 
genesis that  the  surgeon  will  be  equipped  to  care  for  the 
unusual  and  more  dreaded  cases. 

In  a  given  infection  the  surgeon  should  first  read  the 
chapter  upon  "Diagnosis  and  Treatment  in  General." 
This  will  indicate  into  which  group  the  particular  case  will 
fall  and  will  direct  the  student  to  the  proper  sections  of 
the  book  where  cases  of  that  nature  are  discussed  more  in 
detail. 

Warning  should  still  be  given  as  to  care  in  the  diagnosis 
and  treatment  of  tenosynovitis.  An  increasing  experience 
has  demonstrated  that  with  careful  and  intelligently 
directed  treatment,  hands  suffering  even  from  this 
dreaded  complication  may  be  restored  to  complete 
function. 

It  is  a  pleasure  to  acknowledge  my  indebtedness  to 

Drs.   Koch,   Woolston,   Davis  and   Day  for  aid   in   the 

present  revision. 

A.  B.  K. 

Chicago,  1921. 

(iii) 


CONTENTS. 


CHAPTER  I. 

INTRODUCTION:  SCOPE  AND  CLASSIFICATION  OF  TYPES 
OF  INFECTIONS. 

History 17 

Scope  and  Classification  of  Types ...       20 


PART  I. 

SIMPLE  LOCALIZED  INFECTIONS  AND  ALLIED  MINOR 
CLINICAL  ENTITIES. 

CHAPTER  n. 

INFECTIONS  OF  THE  DISTAL  PHALANGES. 

Felons 25 

Treatment 29 

Paronychia 33 

Treatment '35 

Subepithelial  Abscesses 39 

Herpes 40 

CHAPTER  HI. 

CARBUNCULAR  INFECTIONS. 

Anatomical  Considerations  and  Pathogenesis .  41 

Treatment    .  _ 45 

Differential  Diagnosis - 49 

Oidiomycosis 49 

Chronic  Stapliylococcus  Processes 51 

CHAPTER  IV. 

MISCELLANEOUS  ABSCESSES. 

Collar-button  Abscess  (Shirt-stud  Abscess)  (Frog  Felon) 55 

Treatment 57 

Localized  Abscesses  in  the  Thenar  and  Hypothenar  Spaces 57 

(V) 


vi  CONTENTS 


PART  II. 

GRAVE  INFECTIONS:  TENOSYNOVITIS,  FASCIAL-SPACE 

ABSCESSES,  LYMPHANGITIS  AND  ALLIED 

CONDITIONS. 

CHAPTER  V. 

DIAGNOSIS  IN  GENERAL, 

Lymphangitis 60 

Tenosynovitis 61 

Fascial-space  Infection 55 

Diagnosis  of  Extensions  from  Various  Sites ■    .      .      .      .  70 

CHAPTER  VI. 

GENERAL  PRINCIPLES  OF  TREATMENT. 

Prophylaxis 71 

Rest 71 

Drugs 72 

Passive  Hyperemia 72 

Hot  Moist  Dressings 73 

Hypertonic  Salt  Solution 75 

Prophylactic  Incision 76 

Drainage 77 

Stimulation  of  Excretion 79 

Massage 79 

Baking  in  Dry,  Hot  Air 79 


SECTION   I. 

THE  ANATOMY  OF  THE  HAND  AND  FOREARM,  WITH  ESPECIAL 

CONSIDERATION  OF  ITS  RELATION  TO  INFECTIONS  OF 

THE  SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES. 

CHAPTER  VII. 

METHODS  OF  STUDY  IN  GENERAL:  A  STUDY  OF  SERIAL 

CROSS-SECTIONS  OF  THE  HAND,  WITH  PARTICULAR 

RELATION  TO  THE  FASCIAL  SPACES. 

Methods  of  Study 81 

A  Study  of  Serial  Cross-sections,  with  Particular  Relation  to  the  Fascial 

Spaces 84 

Middle  Palmar  Space 90 

Thenar  Space 91 

Hypothenar  Space 94 

Discussion  of  the  Relations  of  the  Middle  Palmar  and  Thenar  Spaces  96 

Resume 98 


CONTENTS  vii 


CHAPTER  VIII. 

THE  TENDON  SHEATHS:  A  DISCUSSION  OF  THEIR  ANATOMICAL 

DISTRIBUTION  AND  RELATIONS,  WITH  SURGICAL 

DEDUCTIONS. 

Sheaths  upon  the  Flexor  Surface 100 

The  Sheaths  of  the  Index,  Middle  and  Ring  Fingers 101 

The  Radial  Bursa  and  the  Tendon  Sheath  of  the  Flexor  Longus  PoUicis  102 

The  Ulnar  Bursa  and  the  Sheath  of  the  Tendon  of  the  Little  Finger     .  103 

The  Intercommunication  of  the  Sheaths 107 

Sheaths  upon  the  Dorsum 110 


CHAPTER  IX. 

THE  RELATION  BETWEEN  THE  SYNOVIAL  SHEATHS  AND  THE 
FASCIAL  SPACES  — A  STUDY  BY  EXPERIMENTAL  INJECTION 
OF  THE  OUTLINES,  BOUNDARIES  AND  DIVERTICULA  OF  THE 
FASCIAL  SPACES  AND  THE  RELATION  OF  THESE  TO  THE 
SYNOVL^L  SHEATHS. 


The  Relation  of  Tendon-sheath  Rupture  to  the  Fascial  Spaces 


116 
116 
117 
119 
122 
123 


Injection  via  the  Tendon  Sheath  of  the  Middle  Finger    . 

Injection  via  the  Tendon  Sheath  of  the  Ring  Finger 

Injection  via  the  Tendon  Sheath  of  the  Little  Finger 

Injection  via  the  Tendon  Sheath  of  the  Index  Finge'r 

Injection  via  the  Tendon  Sheath  of  the  Flexor  Longus  Pollicis 

General  Deductions  as  to  Relation  of  Tendon  Sheaths  to  Fascial  Spaces  125 
The  Normal  Boundaries  of  the  Fascial  Spaces  and  the  Position  of  Secondary 

Abscesses  in  Case  of  Extension  from  the  Spaces 126 

The  Middle  Palmar  Space .  126 

Injection  via  the  Tendon  Sheath  of  the  Ring  Finger      ....  126 

Injection  through  the  Palmar  Fascia 127 

Injection  through  Palmar  Fascia  into  Middle  Palmar  Space    .      .  131 

Injection  along  Lumbrical  Muscle  of  Ring  Finger 131 

Thenar  Space 132 

Injection  via  the  Tendon  Sheath  of  the  Index  Finger    ....  132 

Injection  of  the  Thenar  Space  under  Forcible  Pressure       .      .      .  134 
Injection  through   Palmar  Fascia  in  Attempt  to  Reach  Thenar 

Space 137 

Dorsal  Subcutaneous  Space 138 

Injection  between  the  First  and  Second  Metacarpals     ....  138 

Injection  between  the  Second  and  Third  ^letacarpals  ....  139 

Dorsal  Subaponeurotic  Space 139 

Injection  under  Tendons  of  Dorsum 139 

Hypothenar  Space 1-10 

Resume  of  Preceding  Experiments  as  to  Boundaries,  Diverticula  and 

Extension  from  the  Fascial  Spaces 141 


viii  CONTENTS 


CHAPTER  X. 

ANATOMY  OF  THE  FOREARM  IN  RELATION  TO  INFECTIONS. 

Anatomy  in  General 147 

Serial  Cross-sections  of  the  I'orearm 148 

Experimental  Injections  of  the  Fascial  Spaces  of  the  Forearm     ....  152 

Injection  of  the  Radial  Bursa 152 

Injection  of  the  Ulnar  Bursa 153 

Injection  from  the  Mid-palmar  Space 154 

Resume  of  Findings  by  Dissection  and  Experimental  Injections              .      .  157 


SECTION   II. 

THE  SURGICAL  CONSIDERATION  OF  TENDON-SHEATH 

INFECTIONS  AND  FASCIAL-SPACE  ABSCESSES  OF 

HAND  AND  FOREARM. 

CHAPTER  XI. 

PATHOGENESIS— SOURCE  OF  INVOLVEMENT  OF  THE 
TENDON  SHEATHS  AND  FASCIAL  SPACES. 

Etiology  in  General 159 

Source  of  Involvement  of  the  Various  Sheaths 160 

Extension  from  One  Sheath  to  Another 161 

Source  of  Involvement  of  the  Important  Fascial  Spaces  in  the  Hand     .      .  164 

Involvement  from  the  Tendon  Sheaths 164 

Direct  Implantation  of  the  Infection  in  the  Spaces 165 

Involvement  by  Lymphatic  Extension ...  169 

Extension  from  One  Fascial  Space  to  Another 171 

Recapitulation  as  to  Source  of  Involvement  of  the  Fascial  Spaces  .      .  178 

Resume 179 

CHAPTER  XII. 

THE  SPREAD  OF  INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS. 

The  Probable  Extensions  from  Primary  Foci  on  the  Fingers        .      .      .      .  180 

The  Spread  of  Infection  Involving  the  Index  Finger 180 

Fascial-space  Extension 180 

Synovial  Sheath  Extension 183 

The  Spread  of  Infection  Involving  the  Thumb 188 

The  Spread  of  Infection  Involving  the  Middle  Finger 189 

The  Spread  of  Infection  Involving  the  Ring  Finger 191 

Infection  Spreading  from  the  Little  Finger 192 

Infections  Beginning  in  the  Palm  and  Dorsum 193 

Resume 194 


CONTENTS  ix 


CHAPTER  XIII. 

THE  PATHOLOGY  OF  TENDON  SHEATH  AND  FASCIAL-SPACE 

ABSCESSES. 

The  Tendon  Sheath  Proper 197 

The  Fascial-space  Abscesses 199 

CHAPTER  XIV. 

THE  SYMPTOMS,  SIGNS  AND  DIAGNOSIS  OF  TENOSYNOVITIS 
AND  FASCIAL-SPACE  ABSCESSES. 

The  Symptoms,  Signs  and  Diagnosis  of  Acute  Tenosynovitis       .                  .201 
Symptoms,  Signs  and  Diagnosis  of  Extensions  from  Infections  Begin- 
ning in  the  Little  Finger 204 

Extension  to  Ulnar  Bursa 204 

Extension  to  Radial  Bursa  .  .  207 

Extension  to  Forearm 208 

Extension  to  Lumbrical  and  Palmar  Spaces 208 

Symptoms,  Signs  and  Diagnosis  of  Extensions  from  Infections  Begin- 
ning in  the  Index,  Middle  an*d  Ring  Fingers 209 

Symptoms,  Signs  and  Diagnosis  of  Extensions  from  Infections  Begin- 
ning in  the  Radial  Bursa 213 

The  Symptoms,  Signs  and  Diagnosis  of  Fascial-space  Abscesses        .      .      .  215 

The  Middle  Palmar  and  Thenar  Spaces 216 

The  Hypothenar  Space ^ 222 

Dorsal  Abscesses 222 

Forearm  Abscesses 223 

Differential  Diagnosis 224 

CHAPTER  XV. 

THE  TREATMENT  OF  ACUTE  SUPPURATIVE  TENOSYNOVITIS 

—GENERAL  CONSIDERATIONS— A  REVIEW  OF  THE 

LITERATURE. 

Excerpts  from  the  Literature 227 

CHAPTER  XVI. 

THE  TREATMENT  OF  ACUTE  SUPPURATIVE  TENOSYNOVITIS 
.      —DISCUSSION  OF  TECHNIQUE. 

Treatment  while  the  Diagnosis  may  be  in  Doubt 245 

Technique  of  Treatment  after  Diagnosis  is  Made 246 

Treatment  of  Tenosynovitis  of  the  Index,  Middle  and  Ring  Fingers    .  248 

When  the  Involvement  of  Adjacent  Areas  has  Begun    ....  250 

TKe  Index  Finger 250 

The  Middle  Finger 251 

The  Ring  Finger 252 


X  CONTENTS 

Technique  of  Treatment  after  Diagnosis  is  Made — 

Treatment  of  Tenosynovitis  of  the  Little  Finger  and  Ulnar  Bursa     .  252 

Treatment  of  Extensions  from  the  Little  Finger  and  the  Ulnar  Bursa  259 
Treatment  of  Inflammation  of  the  Tendon  Sheath  of  the  I-ong  Flexor 

of  the  Thumb 261 

Synovial  Sheaths  on  the  Dorsum 271 

After-treatment 272 


CHAPTER  XVII. 

THE  TREATMENT  OF  FASCL^L-SPACE  ABSCESS. 

The  Middle  Palmar  Space 277 

Technique  of  Treament 277 

The  Treatment  of  Combined  Involvement  of  the  Middle  Palmar  and 

Thenar  Spaces 280 

The  Treatment  of  Combined  Involvement  of  the  Middle  Palmar  and 

Subaponeurotic  Spaces 284 

Technique  of  Treatment  of  Abscesses  in  the  Thenar  Space 287 

Technique  of  Treatment  of  Abscesses  in  Subaponeurotic  Space  ....  289 

After-treatment  in  Fascial-space  Abscesses 290 


CHAPTER  XVIII. 

RESUME  OF  ACUTE  SUPPURATIVE  TENOSYNOVITIS  AND 
FASCIAL-SPACE  ABSCESSES— PROGNOSIS. 

Resume 291 

Prognosis 293 


SECTION   III. 
LYMPHATIC  INFECTIONS. 

CHAPTER  XIX. 

THE  RELATION  OF  LYMPHANGITIS  TO  OTHER  TYPES  OF 
INFECTION— DISCUSSION  OF  THE  ANATOMY. 

The  Relation  of  Lymphangitis  to  Otber  Types  of  Infection 295 

Anatomy 296 

The  Lymphatic  Vessels  of  the  Hand  and  Forearm 298 

Superficial  Lymphatics 298 

Deep  Lymphatics        ...  305 


CONTENTS  xi 

CHAPTER  XX. 

LYMPHANGITIS— ETIOLOGY,  PATHOGENESIS  AND 
PATHOLOGY. 

Predisposing  and  Active  Factors  in  the  Production  of  Lymphangitis     .      .  308 

Influence  of  the  Type  of  Germ 310 

Influence  of  the  Anatomy  on  the  Course 313 

Sporotrichosis 317 

Relations  of  Lymphatic  Abscesses  Studied  by  Experimental  Injections     .  318 

Report  of  Injections  of  Forearm  Near  the  Radial  and  Ulnar  Vessels    .  318 

General  Conclusions  in  this  Series  of  Experiments  upon  the  Radial 

Vessels 319 

Experiments  by  Injection  along  Ulnar  i\rtery 320 

Pathology  of  Lymphangitis 320 

Resume 322 

CHAPTER  XXI. 

SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS. 

Symptoms  and  Signs  in.  General 324 

Types 325 

Type  I.  Simple  Acute  Lymphangitis 325 

Type  II.  Acute  Lymphangitis  with  Minor  Local  Complications      .      .  325 

Type  III.  Acute  Lymphangitis  with  Serious  Local  Complications     .  325 

Type  IV.  Acute  Lymphangitis  with  Systemic  Involvement      -.      .      .  325 

Acute  Lymphangitis  with  Serious  Local  Complications 326 

Phlegmonous  Lymphangitis 328 

Frequency  of  Localization  in  Lymphatic  Infection 328 

Acute  Lymphangitis  with  Systemic  Involvement 329 

Deep  Lymphangitis • ,  330 

Systemic  Involvement      . 332 

Postmortem  Statistics 338 

Thrombophlebitis 339 

Resume 340 

CHAPTER  XXn.  . 
PROGNOSIS  IN  LYMPHATIC  INFECTIONS. 

Prognosis  in  Lymphatic  Infections 342 

CHAPTER  XXni. 

THE  TREATMENT  OF  LYMPHATIC  INFECTIONS— GENERAL 
DISCUSSION. 

Discussion  of  Various  Procedures 346 

Local 346 

Hot,  Moist  Dressings 346 

Rest 348 

The  Bier  Treatment •      •      •  348 

Incisions   .     .           , 349 


xu 


CONTENTS 


Discussion  of  Various  Procedures 

Systemic  Treatment 351 

Antagonistic  Drugs 351 

Serum  and  Vaccine  Treatment '  .      .      .      .  352 

Supportive  Measures 353 

Resume 353 

CHAPTER  XXIV. 

THE  TREATMENT  OF  THE  COMPLICATIONS  OF  LYMPHANGITIS. 

Tenosynovitis 355 

Subcutaneous  Abscesses 355 

Periglandular  Abscesses 356 

Subclavicular  and  Shoulder  Abscesses 356 

Systemic  Complications ...  357 

Chronic  Infections;  Repeated  Infections 357 

Resume 364 

CHAPTER  XXV. 

HAND  INFECTIONS  AMONG  EMPLOYES. 

A  Consideration  of  Methods  of  Prevention  and  an  Economic  Plan  of  Treat- 
ment      365 

Prevalence  of  Hand  Infections 366 

Etiology  of  Infections  among  Employes 368 

Prevention  of  Hand  Infections 371 

Active  Treatment  of  Hand  Infections  among  Employes 374 

Ambulatory  Versus  Hospital  Treatment  of  Serious  Hand  Infections     .  379 
Serious  Complicated  Cases  Treated  at  Home  and  Taken  to  Hospital  as 

Final  Resort 380 

Economic  Value  of  Proper  Diagnosis  of  Location  of  Pus  and  Proper  Surgical 

Interference  in  Hand  Infections 381 

Conclusions .  38? 


SECTION  IV. 

ALLIED  INFECTIONS. 

CHAPTER  XXVI. 

ERYSIPELAS,  ERYSIPELOID,  GAS-BACILLUS  INFECTION, 
ANTHRAX. 

Erysipelas 384 

Erysipeloid 385 

Gas-bacillus  Infection 386 

Classic  Gaseous  Gangrene 387 

Toxic  Gaseous  Gangrene 388 

Mixed  Gaseous  Gangrene 388 

Anthrax 392 


CONTENTS  xiii 

SECTION   V. 

COMPLICATIONS  AND  SEQUELS  OF  INFECTIONS  OF  THE  HAND. 

CHAPTER  XXVII. 

FOREARM  INVOLVEMENT  FROM  INFECTIONS  OF  THE  HAND 
—PATHOLOGY  AND  DIAGNOSIS. 

Subcutaneous  Abscesses 396 

Deep  Abscesses 397 

Forearm   Involvement — Abscess   Formation   without   Other   Compli- 
cations   398 

Location  of  the  Abscesses 398 

Symptoms,  Signs  and  Diagnosis 402 

Deep  Forearm  Involvement  Associated  with  Wrist-joint  Invasion  .  404 

Examination  of  the  Radial  Bursa  in  Cadavers 404 

Pathology  Found  in  Serious  Wrist-joint  Involvement 405 

Forearm  Involvement  with  Secondary  Hemorrhage 412 

Resume 415 

CHAPTER  XXVIII. 

TREATMENT  OF  INVOLVEMENT  OF  THE  FOREARM 
SECONDARY  TO  HAND  INFECTIONS. 

Treatment  of  Uncomplicated  Cases 416 

Treatment  in  Cases  where  the  Wrist-joint  is  Involved 421 

Treatment  in  Cases  of  Secondary  Hemorrhage 424 

Resume ■  .      .      .      .  424 

CHAPTER  XXIX. 

SEQUEL/E  OF  INFECTIONS  OF  THE  HAND. 

Chronic  Processes,  Osteomyelitis,  Arthritis,  Contractures  and  Atrophy  426 

I  a  v'C' .ement  of  the  Finger  Proper 427 

Treatment 432 

Involvement  of  the  Hand  Proper  and  the  Metacarpals  and  Carpals     .      .  437 

Pathology 437 

Treatment 444 

Atrophy  and  Contracture        . 448 

Resume    .     " . •  472 

CHAPTER  XXX. 
RESTORATION  OF  FUNCTION  IN  INFECTIONS  OF  THE  HANDS. 

Hydrotherapy ;      ....  477 

Electrotherapy  ............      478 

Massage        .      . .      ...      .      .      .      .      •      .479 

The  Use  of  Splints 480 

Exercise 481 

Occupational  Therapy •  489 

Psychotherapy 492 


INFECTIONS  OF  THE  HAND. 

CHAPTER    I. 

INTRODUCTION. 

SCOPE  AND  CLASSIFICATION  OF  TYPES  OF  INFECTIONS. 

The  accompanying  contribution  to  our  knowledge  of 
infections  of  the  hand  is  the  result  of  several  years'  study, 
comprising  experimental  and  anatomical  investigations 
carried  on  in  conjunction  with  careful  clinical  observation 
of  a  considerable  number  of  cases.  In  the  following 
pages  the  diagnostic  factors  and  incisions  which  this 
work  has  suggested  will  be  described.  Experience  has 
shown  that  with  careful  diagnosis  and  properly  placed 
incisions  we  may  expect  a  restoration  to  complete  function 
in  95  per  cent,  of  the  abscesses  of  the  fascial  spaces;  while 
in  tendon-sheath  infections  the  morbidity  will  be  reduced 
by  full}^  one-half,  and  a  greater  reduction  is  possible  if 
the  profession  as  a  whole  will  learn  to  make  an  early 
diagnosis  in  this  most  lamentable  complication. 

HISTORY. 

Professor  -Albert^  says  that  while  the  word  panaritium 
was  not  used  by  Celsus,  it  is  found  in  the  Arabian  and 
other  ancient  writings,  and  appears  to  be  a  corruption 
of  the  Greek  7raf>ouycd  {Trayd  ouu^)  Paracelsus,  Dorneus,  and 
others  have  used  the  words  pandalitium,  passa,  panaris, 
and  panarium,  and  it  cannot  be  said  whether  these  refer 

'  Chin,  1885,  ii. 
2  (17) 


18  INTRODUCTION 

to  different  types  or  are  corruptions  of  the  i  ae  word. 
Concerningthe  elemental  meaningof  panaritiun  7orestus^ 
states:  " Panaritium  s.  Paronychia  tumor  edicit..r,  calidus, 
ulcerosus,  summe  dolorosus,  accidens  in  su  nmitate  digi- 
torum,  in  latere  unguis  et  qiiandoque  tam  vehementer 
afficiens,  nt  vigilias  et  inqiiietudinem  excitet." 

Our  anatomical  knowledge  of  the  lymphatic  vessels 
dates  back  to  the  time  of  Aristotle,  but  it  is  to  Herophilus 
(300  B.C.)  and  Herasistratus  (280  B.C.)  to  whom,  according 
to  Galenic  writings,  we  ought  to  attribute  the  discovery 
of  the  chyliferous  vessels.  These  observations  fell  into 
obscurity,  and  it  was  not  until  1532,  when  Nicolas  Masse 
discovered  renal  lymphatics,  that  the  knowledge  of  the 
subject  began  to  grow.  Following  Eustachius,  Asselli, 
and  others  Vessling  and  Rudbeck  in  the  seventeenth 
century  described  lymphatics  in  the  liver,  pancreas 
lungs,  and  pelvis.  Mascagni,  Lippi,  and  Lauth  followed 
with  admirable  work,  while  Sappey,  in  1876,  published  his 
large  atlas  after  twenty  years  of  work,  when  the  subject 
can  be  said  to  have  been  put  upon  a  scientific  basis. 

It  was  shortly  before  this  time,  however,  that  the 
study  of  lymphatic  abscesses  was  begun.  Bauchet's^ 
treatise,  in  1859,  upon  infections  of  the  hand  lacked  this 
knowledge  to  make  it  a  masterpiece.  From  this  time 
until  the  culmination  of  Sappey's  work  an  acrimonious 
discussion  was  maintained  over  the  subject  of  lymphatic 
versus  synovial  sheath  extension  of  infection.  Gosselin, 
following  dissections,  adduced  proof  that  extension  nearly 
always  progressed  along  synovial  sheaths.  Dolbeau 
meanwhile  presented  a  masterly  discussion,  supported  by 
clinical  evidence,  in  support  of  the  possibility  of  lymphatic 
extension  with  the  formation  of  deep  abscesses.  Cheva- 
let,3  a  pupil  of  Dolbeau,  chose  for  his  doctorate  thesis,  in 

*  Chir.,  lib.  v,  Observat.  16. 

2  Du  Panaris,  Paris,  1859. 

^  These  pour  le  doctorat  en  medecine,  Paris,  1875. 


HISTORY  19 

1875,  make  a  further  contribution  to  the  literature  in 
suppoi  of  his  master's  assumptions,  lirin^ini^;  to  his  aid 
the  brih.ant  investigations  of  Siippey  and  others.  Later, 
Polaillon  a  id  Le  Dentu  supported  the  theories  of  GosseHn, 
although  the  latter  was  led  to  admit  that  the  theories  of 
Dolbeau  might  have  some  justification  in  a  few  cases. 
Since  that  time  the  subject  has  received  little  attention, 
but  we  have  gradually  come  to  assume  that  each  party 
was  too  radical  in  its  claims  and  that  infection  can  spread 
by  either  channel,  an  assumption  that  every  clinician  has 
had  occasion  to  verify. 

In  later  years  a  carefully  observed  series  of  cases  has 
been  reported  from  the  Griefswald  Clinic  by  Max  Tornier,^ 
who  brought  prominently  before  the  profession  Helferich's 
method  of  opening  widely  the  sheaths,  which  was  later 
substantiated  and  discussed  with  carefully  observed  cases 
by  Forssell.^ 

I  wish  to  make,  acknowledgment  of  abstracts  which  I 
have  taken  freely  from  these  authors.  Forssell  particu- 
larly has  written  a  most  masterly  article  upon  teno- 
synovitis. I  am  forced,  however,  to  take  issue  with  him 
as  to  certain  methods  of  treatment.  Concerning  these 
and  the  various  modern  ideas  as  to  the  treatment  of 
tenosynovitis,  full  reference  will  be  found  in  the  chapter 
dealing  with  that  subject. 

In  spite  of  the  fact  that  from  earliest  times  the  import- 
ance of  the  subject  has  been  recognized,  neither  in  text- 
books nor  in  special  articles  can  the  student  find  clear 
descriptions  of  the  various  types  of  acute  infections,  with 
the  methods  Df  their  diagnosis  and  treatment.  This  I 
shall  here  attempt  to  give. 

1  Beitrage  zur  Kenntnis  schwerer  Phlegmonen.  Inaugural  Dissertation, 
Griefswald,   1891. 

2  Klinische  Beitrage  zur  Kenntnis  der  akut  septischen  Eiterungen  der  Sehnen- 
scheiden  der  Hohlhand  besonders  mit  Riicksicht  auf  die  Therapie.  Nordiskt 
mediciniskt  Arkiv,  1903,  Abt.  i,  Heft  3. 


20  INTRODUCTION 

SCOPE  AND  CLASSIFICATION  OF  TYPES. 

It  is  manifest  that  if  we  are  to  have  a  clear  idea  of  the 
various  phases  of  infections  of  the  hand,  it  will  be  necessary 
to  divide  the  subject  into  various  types,  depending  upon 
the  nature  of  the  infection  and  the  results  it  produces. 
It  should  be  understood  that  we  are  dealing  with  acute 
infective  processes,  and  not  those  associated  with  syphilis, 
tuberculosis,  and  other  chronic  infections,  although  the 
general  principles  laid  down  by  the  anatomical  and  ex,..ri- 
mental  researches  will  be  found  to  be  applicable  there  also. 

I  have  divided  the  subject  in  general  as  follows: 

1.  Simple  localized  infections  and  allied  minor  clinical 
entities. 

2.  Grave  infections. 

(a)   Discussion  of  diagnosis  and  treatment  in  general. 

(6)  Tenosynovitis  and  fascial-space  abscesses. 

(c)  Acute  lymphangitis  and  allied  infections. 

{d)  Complications  and  sequelae  of  acute  infections. 
It  is  true  that  in  certain  cases  we  shall  find  all  three 
of  the  graver  types  present — i.  e.,  a  lymphangitis,  a  teno- 
synovitis, and  a  fascial-space  abscess — yet  in  a  majority 
of  cases  only  one  type  will  be  found.  If  they  are  com- 
bined, the  symptoms  and  signs  of  each  are  present,  and 
each  will  demand  a  separate  and  distinct  form  of  treat- 
ment, for  in  opening  a  synovial  sheath  infection  we  do 
not  by  any  means  drain  the  fascial  spaces,  nor  vice  versa. 
Again,  unless  we  have  a  clear  picture  in  our  minds  of 
fascial-space  infection,  and  in  a  given  case  do  not  deter- 
mine whether  or  not  it  is  present  in  an  acute  tenosynovitis 
— and  the  diagnosis  is  by  no  means  easy — we  might  so 
make  our  incision  in  the  synovial  sheath  that  the  fascial 
spaces  would  become  infected  unnecessarily;  and  in  a 
patient  who  depends  upon  his  hands  for  his  livelihood, 
such  an  error  becomes  criminal  carelessness. 

Again,    while    a    lymphangitis    may    become    a    teno- 


SCOPE  AXD  CLASSIF/CATfOX  OF  TYPES  21 

synovitis  or  fascial-space  infection,  in  a  great  majority 
of  cases  it  remains  a  clinical  and  pathological  entity,  and 
the  mistake  frequently  made  of  assuming  this  relationship 
and  treating  it  accordingly  is  responsible  for  the  gra\'est 
errors  and  most  serious  consequences,  both  as  to  morbidity 
and  mortality. 

In  a  great  majority  of  cases  the  differentiation  of  these 
types  can  be  made,  but  I  know  of  no  single  rule  by  which 
it^.can  be  done.  The  requisite  knowledge  comes  only  with 
a  clear  understanding  of  the  basic  principles  of  inflamma- 
tion produced  by  the  various  bacteria,  coupled  with  a 
knowledge  of  the  anatomical  relations  peculiar  to  the  hand 
and  a  study  of  the  course  any  given  infection  will  normally 
pursue.  It  has  therefore  seemed  necessary  to  give  in 
some  detail  the  anatomical  and  experimental  investiga- 
tions upon  which  my  deductions  are  based,  rather  than 
to  state  dogmatically  the  rules  upon  which  a  diagnosis 
should  be  made  and  the  various  incisions  which  I  have 
found  to  lead  to  the  most  rapid  recover}'.  If  one  will 
take  the  time  to  fix  in  mind  the  fundamental  facts  which 
are  here  discussed,  he  will  have  no  difficulty  in  applying 
them  to  any  given  case.  The  technical  procedures  inci- 
dent to  the  operations  are  easily  learned  and  applied.  In 
almost  all  cases  the  difficulty  has  been  an  improper 
diagnosis,  both  as  to  the  nature  of  the  infection  and  the 
position  of  the  pus. 

Therefore,  I  wish  to  emphasize  that  while  for  the 
sake  of  clearness  a  brief  resume  of  the  contents  has  been 
introduced  into  certain  chapters,  the  careful  surgeon  will 
find  It  necessar\'  to  read  the  context  for  the  coordination 
of  the  various  data. 

It  will  be  found  that  lymphatic  infections  follow  a 
distinct  anatomical  and  clinical  course,  having  at  all 
times  the  possibility  of  producing  certain  definite  compli- 
cations which  may  be  prognosticated  and  anticipated. 
We  shall  see  that  the  tendon-sheath  infections  pursue 


22  INTRODUCTION 

definite  lines  of  invasion,  and  the  position  of  the  pocket 
of  pus  when  rupture  occurs  can  l^e  prognosticated,  so  that 
incisions  can  be  made  early  at  these  sites  and  further 
extensions  prevented. 

Concerning  the  fascial  spaces  it  will  be  shown  that: 
{a)  There    are    certain    well-defined,    uniform    spaces 
upon  the  fingers,  palm,  and  dorsum  of  the  hand  in  which 
pus  can  accumulate. 

(b)  There  are  definite  anatomical  channels  by  which 
infection  arising  in  a  given  site  will  extend  to  certain 
of  these  spaces,  while  certain  other  spaces  will  remain 
uninvolved;  hence  the  diagnosis  of  the  position  of  the 
pus  is  simplified  and  the  proper  site  for  the  incision 
determined. 

(c)  There  are  definite  anatomical  channels  by  which 
pus  can  spread  from  the  uniform  spaces  mentioned,  and 
when  this  occurs,  the  position  of  the  pus  can  be  prog- 
nosticated. 

(d)  The  incisions  for  evacuation  of  pus  in  the  various 
spaces  must  be  made  at  definite  sites;  otherwise  important 
structures  may  be  injured,  or  by  ill-advised  incisions 
adjacent  spaces  may  be  opened  at  the  same  time  and  a 
spread  of  the  infection  favored  to  parts  of  the  hand  that 
would  not  have  become  involved  without  this  unfortunate 
surgical  procedure. 

{e)  The  infection  may  persist  for  weeks  and  months 
after  apparently  opening  the  pus  pocket,  if  diverticula 
and  intermediary  chambers  are  not  taken  into  con- 
sideration. 

The  interrelation  of  these  various  facts  will  be  empha- 
sized by  case  reports,  each  of  which  has  been  introduced 
to  illustrate  or  clarify  some  important  clinical  fact.  The 
number  could  have  been  multiplied  many  times,  but  I 
have  tried  not  to  duplicate  these  illustrations. 

We  will  discuss  first  the  slighter  infections,  such  as 
felons,  carbuncles,  paronychia,  etc.,  which  bear  little  or 


SCOPE  AND  CLASSIFICATION  OF  TYPES  23 

no  relation  to  the  more  vserious  types  just  considered. 
It  must  be  remembered  that  they  are  clinical  entities, 
each  having  a  pathology  peculiar  to  itself.  Owing  to 
their  frequency  they  are  of  especial  interest  to  the  practi- 
tioner. While  the  diagnosis  is  easily  made,  the  course  is 
often  unnecessarily  prolonged,  owing  to  a  lack  of  apprecia- 
tion of  the  pathological  anatomy  and  the  proper  means  of 
treatment.  These  types  will  be  discussed  in  the  immedi- 
ately succeeding  chapters,  so  that  they  may  not  be  left 
to  confuse  the  student  later  while  studying  the  graver 
and  more  important  forms. 


PART    I. 

SIMPLE  LOCALIZED   INFECTIONS  AND 
ALLIED   MINOR  CLINICAL  ENTITIES. 


CHAPTER    II. 
INFECTIONS  OF  THE  DISTAL  PHALANGES. 

FELONS,  PARONYCHIA,  SUBEPITHELIAL  ABSCESSES. 

FELONS. 

Felons  are  among  the  most  common  infections  of  the 
distal  phalanx.  The  source  may  be  a  small  pin  prick  or 
unnoticed  injury-,  and  occasionally  no  history  of  injury 
can  be  elicited.  The  patient  first  notices  a  sticking  pain 
in  the  distal  phalanx,  which  rapidly  becomes  throbbing 
in  character  and  most  severe.  He  cannot  rest  or  sleep. 
The  distal  portion  of  the  finger  becomes  red  and  swollen. 
Early  it  is  tender  to  the  touch  and  this  tenderness  is  most 
marked  over  the  site  of  the  infection.  In  the  later  stages, 
after  pus  formation  and  tissue  destruction,  the  sensitive- 
ness disappears.  The  phalanx  is  at  first  tense  from  the 
edema;  more  tense,  in  fact,  than  is  ordinarily  observed 
with  edema,  owing  to  the  peculiar  anatomical  structure, 
which  will  he  discussed  later.  Soon  the  tenseness  is 
replaced  by  an  induration  and  later  by  a  fluctuating, 
boggy  mass. 

The  reason  for  the  peculiar  pathological  condition 
which  is  present  here  in  localized  infection  and  nowhere 
else  in  the  body  is  worthy  of  consideration.  The  ordinary 
conception  of  the  pathogenesis  is  that  which  has  been 


(25) 


26  INFECTIONS  OF  THE  DISTAL  PHALANGES 

attributed  to  Roux,  whether  justly  or  not  I  cannot  say. 
By  this  the  lymphatic  vessels  are  supposed  to  run  perpen- 
dicularly from  the  skin  to  the  periosteum;  infection  thus 
takes  place  under  the  periosteum,  which  is  lifted  off,  and 
necrosis  of  the  bone  ensues.  Against  this  assumption  we 
have  the  very  firm  attachment  of  the  periosteum  to  the 
bone,  Sharpey's  fibers  going  down  into  the  osseous  tissue 
in  such  a  way  that  it  is  practically  impossible  for  the  peri- 
osteum to  be  separated  and  differentiated  as  it  is  elsewhere. 
Moreover,  there  are  certain  anatomical  peculiarities  w^hich 
seem  to  point  to  another  explanation  of  this  frequent 
change,  so  essentially  different  from  that  noted  elsewhere 
^in  the  body.  |The  connective-tissue  framework  is  such  as 
to  produce  a  closed  sac  comprising  the  distal  part  of  the 
phalanx,  thus  differing  from  the  remainder  of  the  finger, 
while  the  glands  lying  in  the  columns  of  fat  present  a 
portal  for  the  entrance  of  pathogenic  bacteria.  This  will 
be  seen  by  examining  the  accompanying  cross  and  longi- 
tudinal sections  of  the  phalanx.  Some  of  the  glands 
may  be  seen  lying  near  the  periosteum.  Of  especial 
interest  is  the  presence  of  the  bloodvessels  which  may  be 
seen  in  the  cross-section,  one  lying  upon  either  side  in  the 
closed  space  and  running  parallel  with  the  phalanx  (Figs. 
I  and  2).  Should  pus  or  edema,  the  result  of  infection, 
develop  to  an  undue  degree  in  this  closed  space,  it  would 
have  no  means  of  free  egress  as  in  the  other  connective- 
tissue  spaces.  Hence  it  would  have  a  tendency  to  shut 
off  the  blood  supply  and  cause  necrosis  of  the  bone.  It 
w^ill  be  seen  by  examining  the  longitudinal  section  that  the 
portion  of  the  bone  involved  is  the  diaphysis,  since  the 
epiphysis  receives  its  blood  supply  before  the  vessels  enter 
the  closed  space.  Anatomically,  then,  we  expect  the 
epiphysis  to  escape  necrosis  in  these  cases,  and  clinical 
observation  corroborates  this  view,  since  the  diaphysis 
is  the  part  of  the  bone  which  is  lost. I  This  finds  its  most 
perfect  example  in  children  and  those  whose  epiphyses 


FELONS  27 

and  diaphyses  ha\-e  not  progressed  to  perfect  Ijony 
union.  It  has  been  my  experience  frequently  to  open 
these  old  felons  in  children  and  have  the  diaphysis  fall 


Bloodvessel. 

I 


Fig.  1. — Transverse  section  of  distal  phalanx,  showing  the  closed  pocket  with 
columns  of  fat  radiating  from  the  bone.  The  glands  are  well  shown  and  demon- 
strate how  easy  it  would  be  for  pathogenic  organisms  to  invade  this  space  through 
these  glands. 


28 


INFECTIONS  OF  THE  DISTAL  PHALANGES 


out  of  the  sac,  where  it  has  been  floating,  a  free  body,  in 
a  sea  of  pus  (Fig.  3).      In  adults,  where  osseous  union 


Fig.  2. — Longitudinal  section  of  the  distal  phalanx  and  articulation.  Note 
the  closed  pocket  of  the  pulp  of  the  finger  and  the  columns  of  fat,  with  glands 
shown  as  dark  dots  spread  throughout.  Note  that  the  epiphysis  is  well  separated 
from  this  pocket. 


PlG_  3. — V.    D.,    aged    nine  years.     Osteomyelitis  of   distal    phalanx   following 
felon.     Note  separation  of  the  epiphysis  and  diaphysis. 

has  taken  place,  an  examination  will  show  the  necrotic 
diaphysis  standing  out  free  from  the  surrounding  tissue, 


FELONS  '         29 

with  the  epiphysis  and  joint,  in  the  early  stages  at  least, 
practically  untouched  b\-  the  destructive  process. 

This  explanation  of  the  pathological  sequence  would 
seem  to  be  more  reasonable  than  that  of  Roux,  and  also 
explains  the  rapid  recession  of  the  process  after  an  early 
opening,  and  the  slow  recovery  when  delay  has  permitted 
the  disease  to  destroy  the  connective  tissue  which  must 
ultimately  be  expelled  as  a  slough. 

When  the  incision  has  been  delayed  or  the  process 
permitted  to  go  on  to  spontaneous  explusion  of  the 
necrotic  matter,  we  find  a  bluish  insensitive  pus  bag  with 
a  sinus  opening  which  frequently  appears  at  one  side  near 
the  nail.  As  a  rule,  the  granulation  tissue  is  not  excessive, 
the  sinus  appearing  more  as  a  simple  canal  uniting  the 
pus  pocket  with  the  exterior.  Fragments  of  seminecrotic 
connective  tissue  often  appear  partially  plugging  the 
opening. 

Treatment. — The  treatment  of  felons  consists  in 
immediate  incision  into  the  infected  area. 

Certain  errors  in  treatment  are  seen  at  times.  The 
first  is  an  incision  made  into  a  phalanx  in  which  there 
is  a  beginning  lymphangitis  and  not  a  localization  in 
the  distal  phalanx.  Such  infections  cause  pain  and 
tenderness  throughout  the  whole  finger,  although  most 
marked  in  the  distal  phalanx.  Again,  the  edema  is  more 
general,  not  having  the  excessive  tenseness  in  the  pulp 
of  the  finger  characteristic  of  a  beginning  felon.  Incision 
here  is  not  only  unnecessary,  but  positively  harmful,  as 
will  be  brought  out  in  discussing  the  subject  of  lymphan- 
gitis as  a  whole. 

The  second  error  consists  in  waiting  until  fluctuation 
has  begun.  If  this  is  done,  unnecessary  pain  is  endured 
by  the  patient.  Moreover,  such  destruction  of  the 
connective'  tissue,  and  even  of  the  bone,  has  occurred  as 
to  cause  not  only  prolonged  convalescence  but  also 
permanent  deformity.     The  incision  should  be  made  as 


30  INFECTIONS  OF  THE  DISTAL  PHALANGES 

soon  as  the  edema  restricted  to  the  distal  phalanx  has 
proceeded  to  a  degree  causing  a  hardness,  but  not  neces- 
sarily the  board-like  feeling  characteristic  of  pus  in  other 
subcutaneous  areas.  In  general,  one  may  say  that  when 
there  is  present  a  painful,  tender  distal  phalanx,  with 
excessive  edema  limited  to  the  phalanx,  incision  should 
be  made. 

Generally  the  patient  comes  for  treatment  after  the 
whole  area  is  involved,  but  at  times  the  finger  will  be 
seen  early  enough  to  decide,  because  of  the  localized 
tenderness,  that  the  pus  has  not  extended  throughout 
the  whole  of  the  closed  space,  in  which  case  the  incision 
should  be  made  over  the  localized  tender  area.  In  those 
cases  in  which  there  is  no  localization,  but  the  whole 
phalanx  seems  involved,  the  incision  should  be  made  some- 
what to  the  side,  and  not  in  the  median  line,  as  is  unfortu- 
nately frequently  done.  The  median  incision  leaves  a 
scar  over  the  site  of  the  tactile  portion  of  the  finger,  so 
that  the  more  delicate  functions  of  that  part  may  be 
impaired.  By  examining  the  cross-sections  here  shown  it 
will  be  seen  that  this  pocket  can  be  opened  by  a  lateral 
incision  just  as  satisfactorily  as  by  a  median  one,  and,  in 
fact,  somewhat  better,  since  the  radiating  columns  of 
fat  and  connective  tissue  will  be  cut  transversely,  thus 
leading  to  more  satisfactory  drainage.  This  incision  should 
be  long  enough  to  open  the  pocket  freely.  If  the  incision 
is  made  early,  one  is  often  surprised  at  the  rapidity  of  the 
recovery.  It  has  been  recommended  by  some  that  the 
incision  should  extend  in  a  circular  direction  around  the 
end  of  the  finger.  While  this  gives  perfect  drainage  it 
leaves  a  scar  upon  the  end  that  interferes  with  function. 
Attention  should  also  be  drawn  to  the  fact  that  if  a  median 
flexor  incision  be  made  it  should  not  extend  beyond  the 
base  of  the  phalanx  but  rather  fall  short  of  it  since  other- 
wise the  development  of  a  tenosynovitis  is  favored.  I 
have  met  this  unfortunate  result  several  times  in  con- 
sultations. 


FELONS  31 

In  those  cases  in  which  incision  has  been  delayed  until 
necrosis  has  ensued,  certain  phenomena  may  be  observed. 
The  connective  tissue  of  the  pulp  may  be  so  destroyed 
that  pus  will  continue  to  discharge  until  the  slough  of 
seminecrotic  tissue  is  expelled.  If  the  opening  is  small, 
recovery  may  be  hastened  by  removing  the  detritus  with 
tissue  forceps.  Its  removal,  however,  must  await  the 
natural  pathological  process  incident  to  all  separation  of 
necrotic  from  living  tissue.  Its  elimination  is  favored, 
however,  by  the  instillation  of  Dakin's  solution  either 
through  a  small  rubber  tube  left  ///  situ  for  a  short  time  or 
by  frequent  injections  through  a  pipette. 

Again,  when  the  bone  is  involved  the  question  often 
arises  as  to  what  disposition  to  make  of  it.  This  will 
vary  with  the  amount  of  involvement.  If  there  is 
complete  separation  of  the  tissues  from  the  diaphysis, 
so  that  it  stands  out  free  like  a  telegraph  pole  in  the  pus, 
it  should  be  removed  at  once  by  the  bone-cutting  forceps, 
remembering  that  the  epiphysis  is  not  involved.  In  the 
case  of  a  child  the  diaphysis  is  often  separated  at  the  time 
of  incision  or  can  be  easily  cut  off  with  the  scissors  because 
of  the  lack  of  bony  union  between  the  epiphysis  and 
diaphysis.  If  the  bone  is  exposed  upon  only  part  of  its 
circumference  it  will  frequently  heal  without  further 
trouble  and  should  be  treated  conservatively.  In  those 
cases  in  which  the  diaphysis  is  removed  no  disability  of  the 
joint  need  be  feared  unless  it  has  become  involved,  a 
complication  occurring  only  in  a  few  instances.  The 
phalanx  will  be  somewhat  short  and  the  finger  nail  may 
be  deformed,  but  movement  will  not  be  seriously  impaired. 
If  the  joint  should  be  seriously  involved  with  much 
destruction  of  bone,  amputation  is  generally  advisable. 
If  the  necrotic  diaphysis  is  curetted  out  a  rapid  restoration 
of  bone  ensues  (Figs.  4  and  5) . 

The  after-treatment  is  the  same  as  that  used  after 
aTi\-  incision  in  acutely  infected  areas,  consisting  essentially 


32 


INFECTIONS  OF  THE  DISTAL  PHALANGES 


in  procedures  designed  to  relieve  pain  and  favor  walling- 
off  of  the  ])roress  by  round-celled  infiltration.  Locally 
nothing  is  sui)erior  to  the  ordinary  dressing  saturated  with 
hot  boric  acid  solution  until  the  acuteness  of  the  inflam- 


FiG.  4. — Osteomyelitis  of  distal  phalanx.  The  first  roentgenogram  shows 
osteomyelitis;  the  second  was  taken  two  days  after  removal  of  diaphysis;  the 
third,  fourth  and  fifth  show  the  various  stages  of  repair  over  a  period  of  six 
months.     The  patient  has  complete  function  in  the  joint. 

mation  subsides.  The  hand  is  elevated  to  lessen  the 
throbbing  pain.  These  measures  are  supplemented  by 
opiates  if  necessary.  After  the  acute  inflammation  sub- 
sides the  finger  is  dressed  by  gauze  thoroughly  saturated 


Fig  5. — Osteomyelitis  following  accidental  vaccination  injury  with  subse- 
quent infection.  The  first  roentgenogram  shows  osteomyelitis;  the  second  was 
taken  immediately  after  the  removal  of  the  diaphysis;  the  third  and  fourth 
pictures  were  taken  during  the  course  of  eight  months  and  show  complete  repair 
of  the  diaphysis.     The  patient  has  complete  function  in  the  joint. 

with  vaseline,  which  permits  the  free  escape  of  pus  and 
permits  the  removal  of  the  dressings  without  ]:)ain  to  the 
patient. 

When  the  resulting  scar  impairs  the  function  of  the 
finger  some  benefit  may  be  secured  by  operation.     The 


PARONYCHIA 


:^3 


accompanying  photographs  of  such  a  finger  demonstrate 
the  result  after  the  obHteration  of  the  contracted  scar 
by  the  transplantation  of  a  free  pad  of  fat  from  the  abdo- 
men to  the  distal  phalanx.  The  patient  was  a  harpist 
and,  as  will  be  seen,  the  contracted  scar  prevented  the 
patient  from  grasping  the  string  by  the  thumb.  An 
incision  was  made  upon  the  opposite  side  of  the  distal 
phalanx,  the  constricting  scar  tissue  cut  and  the  skin 
elevated.  Into  this  space  the  free  transplant  of  fat  was 
placed  and  the  wound  closed.  This  completely  obliter- 
ated  the  depression  and   permitted  satisfactory   use  of 


Fig.  6.- — ^The  first  two  photographs  show  the  scar  contraction  of  the  distal 
phalanx,  and  the  last  two  the  appearance  of  the  finger  after  the  transplant  of 
fat. 

the  thumb  in  playing.  It  should  be  remembered  in  this 
connection  that  some  of  the  fat  will  be  absorbed  conse- 
quently the  finger  should  be  overdistended  (Fig.  6). 


PARONYCHIA. 

Among  the  infections  of  the  distal  phalanx,  none  is 
apparently  so  simple  as  the  paronychia,  or  "run-arounds," 
and  yet  they  frequently  baffle  treatment  for  some  weeks, 
since  the  pathology  may  not  be  understood.  They  begin 
ordinarily  at  one  side  of  the  nail  as  a  simple  infection, 
frequently  from  a  "hangnail." 
3  ' 


34  INFECTIONS  OF  THE  DISTAL  PHALANGES 

This  infection  may  be  of  two  types:  first,  an  acute 
infection,  giving  rise  to  a  small  wheat-grain-sized  abscess 
in  the  subepithelial  tissue  at  the  side  of  the  nail,  which, 
if  opened,  makes  an  immediate  recovery;  if  neglected 
it  spreads  along  the  side  of  the  nail  and  back  to  the  base 
becoming  secondarily  a  typical  "run-around."  More 
often,  however,  a  sluggish  type  develops  from  a  chronic 
infection  along  the  edge  of  a  "hangnail."  For  a  number 
of  days  a  drop  of  pus  or  more  will  exude  from  the  inflamed 
area  about  the  nail  edge.  It  will  then  be  noticed  that  on 
the  same  side  at  the  base  there  is  a  certain  amount  of 
swelling  and  redness,  with  little  or  no  pain.  As  the  days 
pass  the  swelling  and  redness  gradually  extend  about  the 
base  of  the  nail  until  the  opposite  side  is  reached.  At  the 
end  of  two  or  three  weeks  drops  of  pus  will  be  expressed 
from  under  various  parts  of  the  overlying  epithelium 
(eponychium).  A  week  or  two  later  the  entire  nail  may 
be  lifted  off  the  matrix  and  cast  off,  or  at  least  detached 
along  its  entire  base.  Meanwhile,  a  chronic  discharge 
of  pus  continues  from  the  original  nail  sulcus  from  under 
the  eponychium,  since  the  swelling  and  edema  do  not 
favor  satisfactory  drainage.  This  continues  for  some 
time,  during  which  the  matrix  begins  to  proliferate  freely 
and  an  almost  fungus-like  elevation  of  granulation  tissue 
appears,  growing  from  underneath  the  overhanging  cuticle. 
This  picture  of  the  neglected  case  is  not  at  all  uncommon, 
owing  to  the  habit  of  the  patients  to  consider  this  infection 
as  unimportant  and  consequently  to  treat  it  by  poultices 
and  salves.  In  this  they  are  often  abetted  by  the  ill- 
informed  physician.  At  times,  it  is  true,  spontaneous 
recovery  may  take  place,  but  most  often  the  nail  is  lost 
after  a  more  or  less  prolonged  course. 

Let  us  consider  the  pathology  of  these  chronic  inflam- 
mations when  they  spread  to  the  base  of  the  nail.  It  will 
almost  always  be  found  that  the  pus  is  under  the  over- 
hanging edge  of  the  nail.     Upon  extension  the  pus  follows 


PARONYCHIA  35 

around  the  nail  sulcus,  still  imder  the  nail.  The  soft  and 
delicate  nail  root,  under  the  eponychium,  is  raised  entirely 
off  of  the  nail  bed,  although  the  distal  exposed  portion  of 
the  nail  is  still  firmly  attached  to  the  matrix. 

Treatment. — With  a  clear  understanding  of  the 
above  patholog3%  it  is  manifest  that  the  only  proper 
procedure  is  to  allow  escape  of  the  imprisoned  pus.  This 
is  done  by  making  a  longitudinal  incision  along  the  outer 
edge  of  the  nail,  going  back  to  the  base  as  far  as  the 
sulcus,  with  especial  care,  let  me  repeat,  to  cut  to  the 
outer  side  of  the  nail  so  as  not  to  cut  the  nail  bed  or  the 
overhanging  cuticle,  since  if  this  is  done  it  may  result  in 
a  permanently  split  nail  when  it  grows  out  anew.  The 
eponychium  is  now  pushed  back  with  a  sponge  and  the 
point  of  a  sharp  scissors  inserted  under  the  detached  edge 
of  the  nail  and  this  is  cut  off,  together  with  as  much  of  the 
root  of  the  nail  as  has  become  separated  from  the  matrix 
by  the  pus.  It  is  w^ise,  generally,  to  be  on  the  side  of 
radicalism,  since  otherwise  secondary  operations  may 
become  necessary.  ^  After  removing  this  portion  of  the 
nail  the  elevated  flap  of  overhanging  cuticle  is  packed  up 
and  out  of  the  field  by  a  small  strip  of  gauze  saturated 
with  vaseline  to  favor  drainage  for  a  few  days.  A  hot, 
moist  dressing  is  applied  to  the  entire  finger  for  a  couple 
of  days,  after  which  time  a  vaseline  gauze  dressing  or  dry 
dressing  is  applied  as  the  case  may  demand.  The  dry 
dressing  should  not  be  too  voluminous.  It  is  well  to  make 
the  dressing  as  light  as  possible  so  that  the  wound  will 
dry  up.  It  is  wise  to  remove  the  dressing  for  several 
hours  each  dg.y  and  expose  the  finger  to  the  drying  rays 
of  an  electric  light. 

Concerning  those  cases  in  which  more  than  half  of  the 
base  has  become  involved  in  the  swelling  and  redness,  a 
word  further  is  required.  Here  a  second  incision  should 
be  made  upon  the  other  side  of  the  nail,  using  the  same 
precaution  as  in  the  first  incision,  not  to  cut  the  nail  bed 


36 


INFECTION  OF  THE  DISTAL  PHALANGES 


or  the  overhanging  cuticle   (Fig.   7).     The  eponychium 
which  is  now  entirely  vseparated  from  the  epithelium  on  its 


Fig.  7. — Lines  of  incision  used  in  paronychia. 


Fig.  8. — Photograph  of  steps  of  operation  in  paronychia.     F"lap  has  been  raised 
and  the  point  of  the  scissors  inserted  under  the  base  of  the  nail. 

two  sides  is  pressed  back  and  elevated  as  before,  exposing 
the  entire  sulcus.  The  loosened  portion  of  the  nail  in 
these  cases  will  often  comprise  the  entire  nail  root.     This 


PARONYCHIA 


37 


is  completely  removed,  leaving  the  distal  ])ortion  of  the 
nail  still  attached  to  the  matrix.  Gauze  is  packed  in, 
as  before,  to  raise  the  flap  and  secure  drainage  (Fig.  8). 
It  is  not  necessary-  to  remove  the  distal  portion  if  it  is 
not  already  detached.  It  does  not  interfere  at  all  with 
recovery,  and  is  still  of  some  service  after  the  acute 
inflammation  at  the  base  subsides.  The  new  nail  rapidly 
forms,  and  in  growing  out  pushes  the  old  nail  in  front  of  it 
(Figs.  9,  10  and  ii). 


Fig.  9. — Untreated  paronychia. 

In  those  cases  in  which  the  condition  has  been  neglected 
or  in  which  the  liberating  incisions  have  not  been  made 
at  the  sides,  a  considerable  cauliflower-like  growth  of 
granulations  may  appear,  as  has  already  been  mentioned. 
This  is,  of  course,  due  to  the  irritation  incident  to  inade- 
quate drainage.  Hence  we  should  see  that  the  drainage 
is  free.     This  will  be  followed  by  the  formation  of  nail 


38  INFECTION  OF  THE  DISTAL  PHALANGES 


Fig.  10. — All  inflammation  has  subsided  and  new  nail  is  growing  out,  forcing  the 

old  remnant  off. 


Fig.  11. — Complete  recovery  at  the  end  of  seven  weeks. 


SUBEPirilELJA  L  A  BSC ESSES 


39 


and  the  rapid  disapi^carance  of  the  granulations.  1  have 
never  yet  cauterized  these.  In  one  intractable  case  rapid 
relief  was  secured  by  pkicing  a  rubber  band  about  the  base 
of  the  finger,  producing  a  Bier's  hyperemia  for  some  days. 


SUBEPITHELIAL  ABSCESSES. 

It  is  not  at  all  uncommon  for  subepithelial  infections 
to  take  place  either  as  local  processes  or  associated  with 


Fig.  12. — Herpes  of  the  finger. 

more  extensive  infections.  The  epithelium  may  be 
raised  over  a  "considerable  area,  both  upon  the  flexor  and 
the  extensor  surfaces.  This  kind  of  infection  is  frequently 
seen  as  a  local  process  about  the  distal  phalanx,  the  con- 
tents being  generally  a  seropurulent  fluid  of  a  low  grade 
of  virulency. 

The    treatment    consists    in    removing    the    elevated 
epithelial  covering  and  applying  some  dry  dressing  or 


40  INFECTIONS  OF  THE  DISTAL  PHALANGES 

hot  l)oric  dressing  as  the  virulency  of  the  case  demands. 
It  is  essential  that  every  part  of  the  detached  epithehum 
be  removed,  otheru^se  the  moist,  warm  pocket  will  favor 
the  further  development  of  the  infection. 

HERPES. 

Attention  should  be  drawn  to  the  fact  that  herpes  may 
develop  upon  the  fingers,  presenting  here  as  elsewhere 
the  multiple  vesicles  characteristic  of  the  disease.  Those 
patients  who  suffer  from  it  are  subject  to  repeated 
attacks.  The  accompanying  photograph  shows  inade- 
quately a  finger  subject  to  these  repeated  outbreaks 
(Fig.  12). 


CHAPTER   III. 
CARBUNCULAR  INFECTIONS. 

The  carbuncles  which^  develop  on  the  hand  are  typical 
of  that  condition  elsewhere.  Carbuncles,  although  seen 
frequently,  are  often  not  understood  by  the  practitioner 
who  therefore  does  not  take  the  proper  steps  necessary 
to  their  immediate  cure. 

They  ma\'  develop  in  any  portion  of  the  dorsum 
containing  hair  follicles,  their  most  common  site,  there- 
fore, being  the  dorsum  of  the  proximal  phalanges  (Figs. 
1 8  and  19)  and  the  back  of  the  hand  upon  the  ulnar  side. 
The  various  types  of  staphylococci  are  most  often  the 
exciting  organisms.  The  peculiar  pathology  characteristic 
of  this  condition  is  due  to  the  nature  of  the  skin  and 
subcutaneous  tissue  with  its  sweat  glands,  hair  follicles, 
and  columns  of  fat  extending  up  into  the  derma. 

Anatomical  Considerations  and  Pathogenesis. — 
In  an  attempt  to  determine  the  source  of  these  infections 
and  the  cause  of  their  persistence,  I  made  serial  sections 
of  a  portion  of  the  skin  and  identified  the  various  struc- 
tures in  the  succeeding  sections,  without,  however,  being 
able  to  say  definitely  that  the  source  could  be  attributed 
to  either  the  sweat  glands  or  hair  follicles  alone.  Repeat- 
edly on  examination  a  hair  follicle  with  its  sebaceous 
gland  could  be  found  in  the  subjacent  columnse  adiposse; 
on  the  other  hand,  it  almost  as  firequently  occurred  that 
the  convoluted  sweat  gland  would  also  be  found  (Figs.  13 
and  14).  One  could  only  conclude,  therefore,  that  it  was 
possible  for  the  carbuncle  to  begin  from  either,  although  it 
seemed  more  reasonable  to  attribute  its  source  to  the 
hair   and    its    sebaceous   gland.     Garre,    Budinger,    and 

(41) 


42 


CARBUNCULAR  INFECTIONS 


others  have  demonstrated  upon  themselves  that  it  is  very 
easy  to  produce  such  infections  by  rubbing  into  the  skin 
virulent  streptococcus  cultures. 

In  the  accompanying  microscopic  illustration  of  a 
cross-section  of  the  skin,  the  various  columnae  adiposae 
may  be  seen  with  the  hair  follicles,   sebaceous  glands, 


S^lacpcii-'' 
ClanJ 


S II  cat 
Claud 


Fig.  13. — -Sagittal  section  of  the  skin,  showing  columna  adiposa.  At  the  upper 
part  note  the  hair  follicle  with  its  sebaceous  glands  connecting  this  column  of  fat 
with  the  skin.     In  the  lower  portion  of  the  column  of  fat  a  sweat  gland  is  seen. 

and  sweat  glands  in  various  locations  (Fig.  15).  From 
a  study  of  this,  the  course  an  infection  will  pursue  can 
be  seen  readily.  Beginning  in  one  of  the  columnae, 
the  accumulation  finds  readier  escape  downward  into 
the  subjacent  fat.  From  there  it  spreads  laterally  and 
gradually  fills  the  loose  mesh  under  the  skin  and  ascends 


ANATOMICAL  CONST  DERATIONS  AND  PATHOGENESIS     43 

int(;  the  various  columnae,  from  whence  llie  infection 
extends  to  the  surface  from  these  many  sources,  straining 
through  a  sieve,  as  it  were.  As  the  process  persists  the 
central  part  of  the  surface  becomes  necrotic,  and  through 
this  is  extruded  pus  and  seminecrotic  connective  tissue. 
Kven  this  does  not  give  free  drainage,  and  the  process  still 
tends  to  extend  around  the  peripheryi  Meanwhile,  more 
and  more  of  the  overhanging  skin  becomes  destroyed, 


Fig.  14. — Section  parallel  to  the  skin.  Note  that  here  we  have  two  columnse 
adiposse  cut  transversely.  In  one  a  hair  is  seen  and  in  the  other  a  hair  and  a 
sweat  gland.     It  is  readily  seen  how  pus  would  follow  along  these  to  the  surface. 


until  such  time  as  enough  surface  is  destroyed  to  give  free 
exit  to  the  pus  and  the  surrounding  inflammatory  infiltra- 
tion walls  off  the  infection,  which  it  does  with  difficulty, 
owing  to  the  many  interstices  in  the  loose  mesh  of  sub- 
cutaneous tissue  through  which  the  pus  can  extend.  An 
examination  of  a  schematic  cross-section  of  such  an 
inflamed  area  shows  these  various  facts.  Clinically  they 
are  observed  on  the  surface  as  follow^s:     First,  the  central 


44 


CARBUNCULAR  INFECTIONS 


necrotic  area;  about  this  the  area  of  tissue  shows  i)unctate 
pus  exudations;  and  beyond  this  a  bhiish  circumference 


Fig.  15. — A  section  of  the  skin,  subcutaneous  tissue,  and  muscle,  showing  the 
area  in  which  the  pus  of  a  carbuncle  develops  and  how  it  spreads  beneath  the 
skin  and  comes  to  the  surface  through  the  various  dark  lines  in  the  skin  which 
represent  the  hair  follicles.  Note  several  dark  dots  (H)  in  the  fat  underneath 
the  skin.  These  are  cross-sections  of  hairs  which  have  penetrated  beneath  the 
skin  and  lie  in  the  fat. 


through  which  the  pus  has  not  penetrated,  although  it  is 
under  the  skin;  and,  finally,  surrounding  it  all,  an  area  of 
induration  denoting  inflammatory  reaction. 


TREATMENT 


45 


Treatment. — These  cases  are  best  treated  by  a 
crucial  incision,  the  ends  of  which  extend  beyond  the 
edge  of  infiltration,  followed  by  incisions  under  the  skin, 
so  that  this  may  be  raised  off  of  the  underlying  tissue 
(Figs.  1 6  and  17).  The  base  of  the  flaps  should  correspond 
with  the  end  of  the  crucial  incisions.     Hot,  moist  gauze 


Fig.  16. — Schematic  drawing,  showing  the  areas  of  the  carbuncle  with  the  length 
of  incisions  upon  the  skin. 

is  now  packed  under  the  flaps  to  insure  drainage.  The 
patients  are  always  anesthetized,  nitrous  oxide  being 
preferable.  The  reasons  for  carrying  the  incisions  in  the 
skin  beyond  the  edge  of  inflammatory  exudation,  as 
indicated  by  the  induration,  are  difficult  to  understand. 
The  principle  is  directly  opposed  to  the  ordinary  con- 


46 


CARBUNCULAR  INFECTIONS 


ception  of  this  area  as  a  protecting  wall,  which  in  other 
conditions  we  would  use  every  possible  precaution  to 
preserve.  Of  the  advisability  of  the  length,  however,  I 
have  no  doubt,  since  I  have  had  occasion  to  use  this 
method  in  probably  lOO  cases,  and  whenever  the  technique 


Area   of  necrosis 
Area   of  pus 


Area  of  round- 
celled  infiltration 
pus 


Fig.  17. — Schematic  drawing,  showing  areas  of  infection  in  the  carbuncle 
and  the  method  by  which,  through  a  transverse  incision  parallel  to  the  skin, 
the  flaps  are  raised  up.  Note  that  this  incision  F  goes  beyond  the  limit  of  the  area 
of  induration  A;  B,  area  of  round-celled  infiltration  and  some  pus;  C,  area  of 
pus,  most  of  the  fat  being  destroyed;  D,  area  of  necrosis. 

described  has  been  faithfully  carried  out  the  result  has 
always  been  satisfactory.  If,  however,  through  a  con- 
serv^atism  I  fell  short,  the  extension  always  took  place 
along  that  area,  while  the  sides  where  I  had  made  the 
long  incisions  would  go  on  to  satisfactory  recovery.   This 


TREATMENT  '  47 

same  holds  true  for  carbuncles  of  the  neck  and  other 
areas. 

The  cuts  parallel  to  the  skin  designed  to  free  the  skin 
from  the  deep  fascia  should  be  made  about  midway 
between  these  two  layers,  going  back  through  the  area 
of  induration  also  (Fig.  17).  Any  arterial  bleeding  is 
stopped,  but  the  venous  oozing  is  controlled  by  packing, 
and  this  packing  should  be  sufficient  to  raise  the  flaps 
well  up.  The  packing  is  removed  at  the  end  of  twenty- 
four  hours,  and  the  flaps  allowed  to  fall  back.  If  there 
is  not  much  venous  oozing,  the  gauze  is  thoroughly 
saturated  with  vaseline,  which  allows  drainage  and  permits 
removal  without  pain  to  the  patient. 

If  there  is  any  free  slough  it  is  removed  at  the  time 
of  operation.  It  is  not  necessary^  to  curette  or  cut  away 
any  tissue  whatever.  Dakin's  solution  applied  after  the 
approved  method  hastens  the  removal  of  this  necrotic 
tissue.  The  removal  of  any  of  the  skin,  no  matter  how 
much  damaged  and  fragmentary^  should  be  condemned, 
since  one  is  alwa^^s  surprised  at  the  rejuvenation  of 
apparently  hopelessly  injured  skin.  After  repair  has 
begun  I  have  often  found  the  flaps  to  fall  into  place  and 
leave  a  granulating  area  no  larger  than  a  dime,  where  it 
had  seemed  the  entire  area  must  be  lost.  For  that 
reason  also  one  should  condemn  most  severely  the  pro- 
cedure advocated  by  some  of  excising  the  entire  area. 
On  the  other  hand,  the  crucial  incision  without  under- 
cutting and  raising  the  flaps,  is  futile  in  a  majority  of 
cases,  leading  to  repeated  operations  and  prolonged 
convalescence. 

Case  I. — In  this  connection  the  history  of  a  patient  sent 
to  me  for  treatment  is  interesting.  When  first  seen  he  had 
been  suffering  for  three  weeks  with  a  carbuncle  on  the  dorsum 
of  the  left  hand.  It  had  begun  as  a  small  pimple  on  the  ulnar 
side,  and  incisions  had  been  made  on  six  different  occasions 
at  different  points.    The  infection  had  spread  to  involve  the 


48  CARBUNCULAR  INFECTIONS 

entire  dorsum,  and  had  extended  to  the  flexor  surface  around 
the  thumb  and  the  wrist  at  the  ulnar  side.  The  sloughing 
connective  tissue  was  being  extruded  from  the  incisions  and 
small  necrotic  ostea  which  had  appeared  over  its  surface.  In 
other  places  it  had  the  characteristic  appearance  of  a  car- 
buncle. 

The  patient  was  anesthesized  and  a  crucial  incision  made, 
not,  however,  carrying  the  incision  the  full  length  of  the 
infected  area,  for  fear  of  impairing  the  nutrition  of  the  flaps. 
The  entire  area,  however,  was  undermined  and  gauze  satur- 


FiG.  18.— Beginning  carbuncle  on  the  ulnar  side  of  the  dorsum  of  the  hand. 

ated  with  hot  boric  acid  solution  carried  to  the  edge.  An 
immediate  cessation  of  the  process  took  place  except  at  the 
wrist,  where  a  subsequent  incision  had  to  be  made,  owing 
to  the  inadequacy  of  the  early  incision.  When  the  flaps 
finally  healed,  it  was  found  that  no  grafting  was  necessary. 
So  much  of  the  skin  had  retained  its  vitality  that  the  denuded 
areas  were  soon  covered  by  epithelium. 

At  times  I  have  been  compelled  to  cover  a  small  denuda- 
tion by  a  Thiersch  graft  from  the  patient's  body.  This 
should  be  done  as  soon  as  a  good  granulating  base  has 
been   assured.     This,    in   my   experience,    is  more  often 


DIFFERENTIAL  DIAGNOSIS 


49 


necessary  on  the  dorsum  of  the  finger  than  on  the  back  of 
the  hand. 

The  illustrations  show,  in  both  cases,  beginning  car- 
buncles (Figs.  1 8  and  19).  The  one  on  the  hnger  had 
been  treated  a  week  before  it  came  under  my  observation, 
and,  after  incision,  was  dressed  only  twice  and  was  entirely 
well  in  a  week.  The  one  on  the  dorsum  of  the  hand  had 
been  treated  for  six  days  after  a  simple  incision.  After 
opening  it  properly  and  applying  the  Bier  suction  cup, 
which  I  have  at  times  used  with  success,  entire  healing 


Fig.  19. — Carbuncle  on  the  dorsum  of  the  proximal  phalanx. 

followed  in  a  week.  This  picture  of  an  apparently  simple 
case  is  presented,  since  it  is  in  such  that  the  diagnosis  is 
not  made.  They  are  considered  simple  abscesses.  The 
more  severe  cases  with  the  punctate  areas  of  pus,  if  they 
are  acute,  are  recognized  by  all. 

Differential  Diagnosis. — Oidiomycosis. — There  is  a 
more  chronic  type  of  infection  of  this  area  which  may 
be  mistaken  for  oidiomycosis  (blastomycosis)  and,  con- 
versely, an  oidiomycosis  may  be  construed  to  be  a  sub- 
acute carbuncle.  The  appearance  of  these  oidiomycotic 
areas  is  very  characteristic,  presenting  a  rather  clean 
4 


50  CARBUNCULAR  INFECTIONS 

granulating  surface,  while  the  edge  which  is  undermined 
appears  as  if  moth-eaten,  with  pus  droplets  exuding 
through.  In  some  parts  the  process  will  apparently  have 
healed  and  be  covered  by  a  thin,  shining  sheet  of  epithe- 
lium. Over  the  granulating  area  the  skin  is  not  com- 
pletely destroyed,  since  areas  of  epithelium  remain  which 
rapidly  produce  epidermization  when  the  process  is  halted. 
The  diagnosis  can  be  made  readily  by  securing  pus 
from  the  abscess  and  examining  the  unstained  smear 
diluted  with  4  per  cent.  KOH,  or  with  normal  salt  solu- 


FiG.    20. — Oidiomycosis.     (Photograph   loaned   by   Dr.  Ormsby.)     Typical  and 
practically  identical  with  that  seen  in  Case  II. 

tion.  This  finding  may  be  corroborated  by  microscopic 
examination  of  the  skin,  which  will  show  the  proliferating 
rete  with  miliary  abscesses. 

One  such  case  came  under  my  care  in  which  the  condi- 
tion had  been  held  to  be  a  chronic  infection  and  had  been 
treated  with  salves  and  applications  until  the  entire  dor- 
sum was  covered  by  the  ulcerated  area.  The  edges  were 
curetted  thoroughly  and  potassium  iodide  given  in  large 
doses  (400  grains  per  day).  The  lesion  finally  healed 
after  some  weeks,  during  which  it  was  necessary  to  remove 
the  extending  edge  in  various  parts  several  times.     Un- 


DIFFERENTIAL  DIAGNOSIS  ,  51 

fortunately,  I  h^ive  not  a  photograph  of  the  lesion,  l)iit  it 
was  practically  identical  with  that  shown  by  the  photo- 
graph (kindly  loaned  me  by  Dr.  Ormsby)  of  the  same 
condition  in  a  patient  of  his  (Fig.  20). 

Case  II. — Mr.  G.  C,  of  Gallion,  Ohio,  was  referred  to  me 
with  the  history  that  seven  months  before  he  noticed  a  small 
pimple  on  the  dorsum  of  the  right  hand.  The  patient  opened 
the  pimple  with  scissors,  following  which  the  sore  began  to 
spread  by  peripheral  extension.  A  couple  of  weeks  later  a 
similar  lesion  began  on  the  neck,  as  a  result  of  the  patient 
scratching  a  pimple  there.  These  two  lesions  continued  to 
spread  until  about  three  weeks  before  I  saw  the  patient,  when 
two  small  pustules  appeared  upon  the  right  arm,  and  since 
that  several  small  lesions  had  appeared  on  the  trunk,  all 
possibly  implanted  through  self-contamination  by  scratch- 
ing. The  lesion  on  the  hand  was  of  approximately  the  size 
shown  in  the  illustration.  That  upon  the  neck  was  about  one 
and  one-half  inches  in  diameter.  The  characteristic  appear- 
ance already  described  was  present.  The  areas  were  excised, 
following  which  all  the  lesions  disappeared  except  that  upon 
the  hand.  This  also  finally  disappeared  under  curettage  and 
large  doses  of  potassium  iodide. 

The  condition  is  essentially  different  from  the  picture 
presented  by  the  foul  sloughing  syphilitic  ulcer  or  the 
blue  undermined  tuberculous  process. 

Chronic  Staphylococcus  Processes. — We  may  have  a 
chronic  staphylococcus  process  upon  the  dorsum,  as  has 
already  been  said,  which  may  be  wrongfully  diagnosti- 
cated as  oidiomycosis.  Such  a  case  came  under  my 
observation  with  an  ulceration  upon  the  dorsum  which 
had  involved  during  its  course  a  greater  part  of  the  area, 
some  parts,  however,  showing  pinkish,  glistening  new 
epidermis,  while  others  showed  an  active  process  appear- 
ing as  an  ulcerating  granulating  surface,  or  rather  as  a 
depressed  verrucous  process,  while  the  edges  of  these 
areas  showed  the  advancing  border  of  infection. 
Repeated  examinations,  both  by  culture  and  microscopic 


52 


CARBUNCULAR  INFECTIONS 


tissue  study,  demonstrated  a  pure  culture  of  staphylo- 
coccus. It  is  my  belief  that  the  process  had  become 
chronic  in  its  nature,  owing  to  the  peculiar  anatomy  I 
have  described  as  being  found  here,  coupled  with  lowered 
resistance  to  the  specific  organism  and  the  irritation  of  the 
various  treatments  to  which  it  had  been  subjected.  It 
healed  rapidly  under  bland,  slightly  antiseptic  applica- 
tions.    It  is  my  opinion  that  a  passive  hyperemia  pro- 


FlG.  21. — Chronicstaphylococcusinfectionof  the  dorsum  simulating  oidiomycosis. 

(See  Case  III.) 


duced  by  local  suction  cups  would  also  have  hastened 
recovery  in  this  case.  An  autogenous  vaccine  might 
also  have  helped.  The  case  history,  written  by  the 
patient,  who  was  a  physician,  is  appended.  The  photo- 
graph (Fig.  21 )  shows  the  condition  inadequately. 

Case  III. — "Family    history    negative;    aged    forty- four 
years;  good  health.     On  September  I2,  1910,  I  noticed  skin 


DIFFRRRXTI.  I  /.   /)/.  I CXOSFS  53 

on  middle  knuckle  of  right  hand  flecked  up  as  if  by  a  pin. 
On  the  morning  of  the  15th  I  noticed  some  reddening  of  the 
knuckle  extending  up  into  the  back  of  the  hand,  with  a  slight 
burning  pain.  On  the  morning  of  the  i6th  my  hand  was 
badly  swollen.  Pain  very  severe  when  hand  hung  down,  and 
burning  was  intense. 

"I  treated  it  vigorously  with  wet  dressings  of  bichlo- 
ride, carbolic  acid,  and  boric  acid  alternately.  The  swelling 
subsided  in  a  few  days.  The  pain  was  not  so  severe,  but  the 
burning  sensation  continued.  The  place  where  the  infec-tion 
started  broke  down,  forming  something  like  a  small  ulcer. 
The  infection  then  seemed  to  extend  up  the  back  of  my  hand. 
Every  hair  follicle  seemed  to  be  a  center  of  infection,  breaking 
do^\'n  and  forming  a  small  opening  from  which  exuded  pus. 
I  treated  it  with  iodine,  carbolic  acid,  ointments  of  every 
description,  dry  and  wet  dressings.  With  all  the  treatment 
the  infection  continued  to  spread  over  the  back  of  the  hand, 
with  more  or  less  pain  all  the  time,  but  increasing  at  intervals, 
the  burning  being  almost  continuous. 

"On  December  25,  1910,  becoming  disgusted  with  my  own 
treatment,  and  upon  advice  of  my  neighboring  doctors,  I 
left  for  Chicago.  There  my  hand  was  examined  by  a  number 
of  prominent  physicians.  Each  man  had  a  diagnosis  of  his 
own.  Dr.  W.  L.  Baum's  diagnosis  was  staphylococcus  infec- 
tion. His  diagnosis  was  proved  by  both  culture  and  the 
microscope.     This  was  corroborated  by  Dr.  Kanavel.    _ 

"Was  under  treatment  of  these  physicians,  which  con- 
sisted of  a  bland,  slightly  antiseptic  ointment,  two  weeks 
before  I  noticed  much  change;  but  within  three  weeks  from 
the  time  they  started  treatment  my  hand  was  thoroughly 
healed,  leaving  a  red  scar,  which  yet  remains.  The  scar 
resembles  that  of  a  severe  burn  extending  over  the  entire 
back  of  the  hand." 

These  chronic  low  grade  infections  have  been  found  in 
other  locations.  While  often  the  general  resistance  is 
low  frequently  some  local  causative  factor  w^ill  be  found, 
as,  for  instance,  an  impaired  trophic  nerv^e,  constant  local 
irritation  due  to  solutions  the  hand  may  be  immersed  in, 
irritating  dressing,  etc.,  or  at  times  it  may  be  due  to  the 
fact  that  the  infection  is  located  at  the  joint  level  and 


54  CARBUNCULAR  INFECTIOXS 

constant  flexion  and  extension  keeps  the  part  from  healing. 
Such  a  factor  was  present  in  the  patient's  finger  shown  in 
the  accompanying  photograph.     The  low  grade  process 


Fig.  22. — Chronic  staphylococcic  infection. 

failed  to  heal  until  a  splint  was  applied  preventing  flexion 
of  the  finger.  This  treatment,  supplemented  by  simple 
exposure  of  the  part  to  the  drying  rays  of  an  electric 
light,  brought  about  a  recovery  (Fig.  22). 


CHAPTER   IV. 
MISCELLANEOUS  ABSCESSES. 

COLLAR-BUTTON  ABSCESS  (SHIRT-STUD  ABSCESS) 
(FROG  FELON). 

Among  the  local  infections  of  the  hand  none  is  more 
typical  than  the  collar-button  abscess,  or,  as  the  French 
described  it,  cu  bouton  de  chemise.  This  is  an  abscess 
located  at  the  distal  edge  of  the  palm  under  the  dermal 
and  epidermal  tissues.  Its  peculiar  character  is  due 
to  the  fact  that  at  this  site,  in  workingmen,  the  epithe- 
lium becomes  markedly  hypertrophied,  making  a  dense 
sheet  under  which  the  pus  spreads.  An  infection  present 
under  the  derma  passes  through  this  to  the  epidermal 
tissue,  where  a  second  abscess  forms,  thus  producing  a 
dumbbell-shaped  accumulation  of  pus.  The  pus  may 
locate  primarily  in  the  epidermic  space  and  erode  through 
the  dermal  tissue  rather  than  through  the  dense  epidermis 
to  the  surface,  producing  the  same  condition.  It  is  pos- 
sible that  this  latter  course  is  more  common  than  the 
former. 

These  abscesses  doubtless  owe  their  origin  to  the 
lessened  resistance  due  to  trauma  more  than  those, 
developing  elsewhere,  for  here  the  thickened  area  of 
superficial  cornified  epithelium  is  frequently  opened  by 
cracking,  infection  ensues  in  the  deeper  area  by  lymphatic 
extension,  or,  if  the  cracks  are  deep,  by  direct  inoculation. 
Here  it  finds  excellent  food  for  development,  since  the 
repeated  trauma  has  lowered  the  normal  resistance  found 
in  healthy  tissue. 

In  this  connection  attention  should  be  drawn  to  the 
fact  that  at  the  lower  or  distal  end  of  the  palmar  aponeu- 
rosis the  sheet  may  become  very  thin  in  spots,  particularly 
between    the   processes    which    blend    with    the    tendon 

(55) 


56 


M  ISC  ELLA  NEOrS  A  BSC  ESSES 


sheaths  and  the  superficial  trans\  erse  Hgament,  and  hence 
above  the  canal  for  the  lunibrical  muscles.  Here,  by 
noting  one's  hand,  slight  elevations  of  tissue  may  be  seen, 
cushions  of  fatty  tissue.  Shirt-button  abscesses  may 
enter  this  fat  space  and  spread  down  into  the  cellular 
tissue  of  the  web  pointing  on  the  dorsum  between  the  bases 
of  the  fingers.  Then  the  dumbbell  abscess  would  have 
from  its  second  chamber  a  connection  with  a  still  larger 
one  on  the  dorsum,  a  sort  of  chain  of  lakes  of  pus  (Fig.  23). 
In  relation  to  this,  two  very  interesting  cases  can  be 
cited,  showing  how  infection  apparently  in  nearly  the  same 
site  may  occupy  different  spaces. 


LumbrLcal  m. 
dermis    Dermic  \         Tendon 


'Mid-palmai^  jpac 
4-"'  metacarpal  bone 

Fig.  23. — Schematic  drawing,  showing  distal  pahiiar  abscess  and  its  extension 
into  the  dorsal  tissue  between  the  fingers. 


Case  IV. — From  Northwestern  University  Medical  School 
Dispensary.  History:  C.  B.,  carpenter  by  trade,  has  been 
using  a  chisel  several  days  in  succession  almost  constantly. 
He  hits  the  handle  of  the  chisel  with  the  palm  of  the  hand  to 
force  it  along.  Two  days  ago  the  patient  began  to  note 
tenderness  at  the  distal  portion  of  the  palm  between  the  base 
of  the  index  and  middle  fingers,  about  2  cm.  from  web.  Upon 
examination  this  was  found  to  be  tender  to  pressure,  and  had 
considerable  local  hardness.  Slight  edema  of  dorsum.  Tem- 
perature, 99°;  pulse,  85. 

Treatment. — Incision  was  made  o\qx  the  area  and  a  small 
amount  of  pus  evacuated.  This  was  under  the  deeper  layers 
of  skin  lying  upon  the  transverse  fascia  in  the  pad  of  fat 
found  in  this  region. 


ABSCESSES  IN  THENAR  AM)  IIVPOTHENAR  SPACES    57 

Case  V. — E.  A.  Applied  to  dispensary  of  Northwestern 
University  Medical  School  November  5,  1904.  The  patient 
noticed  pain  and  tenderness  at  base  of  ring  and  middle  fingers, 
about  1.5  cm.  from  web.  Swelling  and  redness  had  been 
increasing  for  four  days.  Temperature,  99°;  pulse,  86. 
Local  swelling  and  redness  at  site  noted,  involving  web  also, 
but  most  marked  above.    Tenderness  noted  as  severe. 

Diagnosis. — Abscess,  subdermal,  above  aponeurosis.  Oper- 
ation: ethyl  chloride  spray,  and  incision  made  over  site  of 
greatest  tenderness,  down  through  deep  layers  of  palmar 
skin.  ^loderate  amount  of  pus  escaped,  and  upon  inserting 
probe  the  larger  part  of  the  pus  was  found  to  be  in  the  cellular 
tissues  of  the  dorsal  web  area,  a  half-inch  back  from  web. 
Through-and-through   drainage   inserted. 

November  9,  nearly  well.    Patient  did  not  return. 

Here  we  see  two  abscesses  to  all  appearances  in  the 
same  place,  yet  in  reality  very  different,  being  so  near 
the  distal  edge  of  the  transverse  ligament  that  while  one 
was  confined  to  the  subdermal  tissue,  the  second  had 
invaded  the  adjacent  cellular  tissue  of  the  web,  and 
spread,  by  continuity  of  spaces,  into  the  loose  tissue  of  the 
dorsum,  where  most  of  the  pus  was  localized. 

Treatment. — The  treatment,  therefore,  consists  in 
being  certain  that  the  second  pocket  is  opened  if  it 
be  present,  and  not  being  content  when  after  incising 
free  discharge  of  pus  is  noted.  Always  examine  carefull}' 
by  inspection  or  a  probe  for  the  second  pocket.  If  the 
pus  has  extended  to  the  space  in  the  web,  it  may  be 
drained  by  a  through-and-through  incision  from  the 
palmar  to  the  dorsal  surface  through  the  web.  I  have  at 
times  cut  the  web  completely  without  noting  any  subse- 
quent impairment  of  function. 

LOCALIZED  ABSCESSES  IN  THE  THENAR  AND  HYPOTHENAR 

SPACES. 

In  the  thenar  region  several  minor  and  indefinite  spaces 
lie  beneath  not  only  the  skin,  but  also  the  fascia  which 
covers  the  muscles.     The  areas  are  small,  however,  and 


58  MISCELLANEOUS  ABSCESSES 

are  generally  opened  through  the  adjacent  skin  before  any 
serious  damage  occurs.  It  is  in  these  areas  more  often 
than  the  thenar  space  proper  that  direct  infection  from 
puncture  takes  place,  since  the  latter  lies  rather  deeply, 
and  to  invade  it  the  puncture  should  enter  between  the 
muscular  body  and  the  adduction  crease,  rather  than  upon 
the  prominent  part  of  thenar  eminence.  It  is  well  to 
bear  this  in  mind  in  making  a  diagnosis  as  to  whether  the 
thenar  space  is  inv^olved  or  not,  since  a  minor  infection 
in  the  superficial  tissues  of  the  thenar  area  either  upon  the 
palmar  or  dorsal  surface  may  be  associated  with  great 
edema  upon  the  dorsum,  and  thus  confuse  the  surgeon  and 
lead  to  a  diagnosis  of  pus  in  the  thenar  space  when  it 
is  uninvolved.  This  error  occurred  in  one  of  my  cases, 
and  is  of  particular  interest,  since  it  demonstrates  that 
treatment  based  upon  this  improper  diagnosis  may  not 
produce  serious  results,  for  here  it  will  be  noted  that  no 
disastrous  sequelae  followed  the  opening  of  the  uninfected 
space  in  conjunction  with  an  abscess  of  the  subcutaneous 
tissue. 

Case  VI. — E.  K.  Injured  December  12,  1904,  at  stock- 
ycU^ds,  by  running  foreign  body  into  thenar  eminence  at  about 
middle  of  palmar  surface.  All  signs  of  localized  infection 
followed,  and  on  December  16  patient  applied  to  dispensary 
for  treatment.  Diagnosis  of  infection  of  the  thenar  space 
made  and  through-and-through  drainage  of  thenar  areas 
instituted,  under  gas  anesthesia.  It  was  seen  that  only  the 
dorsal  subcutaneous  tissue  contained  pus;  tube  was  with- 
drawn and  dorsal  opening  enlarged.  Patient  made  rapid 
recovery  and  was  discharged  in  ten  days,  apparently  fully 
recovered. 

The  hypothenar  area  is  a  closed  space,  as  will  be 
shown  later.  Involvement  of  this  space  is  uncommon 
and  when  it  does  arise  it  has  its  origin  through  direct 
implantation.  It  does  not  spread  out  of  the  space. 
Therefore  there  is  nothing  peculiar  in  its  pathology  and 
the  treatment  of  its  abscesses  consists  in  simple  incision. 


PA  RT    I  I. 

GRAVE  INFECTIONS:    TENOSYNOVITIS, 
FASCIAL-SPACE  ABSCESSES,  LYM- 
PHANGITIS, AND  ALLIED 
CONDITIONS. 


CHAPTER  V. 

DIAGNOSIS  IN  GENER.\L. 

It  is  the  purpose  of  this  chapter  to  give  in  general  the 
diagnostic  factors  of  the  three  severe  types  of  infection, 
viz.,  lymphangitis,  tenosynovitis,  and  fascial-space  infec- 
tion. It  is  not  intended  in  any  sense  as  a  complete  dis- 
cussion of  any,  but  is  introduced  with  the  idea  that  by 
reading  it  the  beginner  may  be  able  in  any  given  case  to 
make  his  diagnosis  in  general,  and  thus  be  directed  to  the 
more  extensive  subsequent  discussions  for  corroboration. 
Therefore  in  various  parts  indication  is  made  where  these 
can  be  found.  It  is  desirable  to  emphasize  this,  since  the 
greatest  difficulty  to  be  met  in  these  cases  is  the  diagnosis. 
Unfortunately,  a  snap  diagnosis  is  too  often  made  and 
incisions  hastily  carried  out  which  jeopardize  the  life 
of  the  patient  and  the  use  of  a  hand,  when  a  little  more 
care  in  the  diagnosis  would  have  led  to  an  immediate 
cure.  It  should  be  emphasized,  further,  that  if  careful 
study  is  made  it  is  possible  in  nearly  every  case  to  diag- 
nosticate not  alone  the  nature  of  the  infection,  but  also 
the  location  of  the  pus  if  it  be  present. 

(59^ 


60  DIACNOSTS  IN  GENERAL 

There  are  certain  facts  which  should  be  remembered: 

1.  The  location  of  the  greatest  swelling  does  not 
indicate  the  position  of  the  pus.  The  excessive  swelling 
comes  in  those  areas  where  there  is  the  largest  amount 
of  loose  cellular  tissue,  i.  e.,  upon  the  dorsum,  while  in 
nine  cases  out  of  ten  the  pus  is  on  the  flexor  surface. 

2.  The  site  of  the  greatest  tenderness  is  of  marked  import- 
ance in  the  location  of  the  pus. 

3.  The  three  types  of  infection,  viz.,  lymphangitis, 
tenosynovitis,  and  fascial-space  infection,  in  the  majority 
of  cases,  are  distinct  processes,  one  type  alone  being 
present  in  a  given  case.  At  times  the  types  may  be 
combined. 

4.  The  treatment  of  the  three  types  is  essentially 
difl"erent,  and  the  gravest  of  errors  will  be  made  if  they 
are  not  differentiated,  since  their  treatment  is  diametric- 
ally opposed  (see  pp.  248  and  346). 

Let  us  now  take  up  these  three  types  in  order. 

LYMPHANGITIS. 

Lymphangitis  may  be  either  superficial  or  deep. 
Deep  lymphangitis  may  end  in  tenosynovitis  or  abscess 
formation  in  the  deep  tissues.  Most  often,  however, 
this  does  not  take  place.  There  is  rapid  increase  of 
swelling  of  the  whole  hand  and  forearm,  with  the  greatest 
redness,  swelling,  and  tenderness  upon  the  dorsum. 
Some  red  lines  of  lymphatic  infection  may  be  seen  running 
up  the  arm,  to  the  axilla  or  elbow.  There  is  an  absence 
of  pain  on  extension  of  fingers  and  thumb.  The  fingers 
can  be  moved  voluntarily  without  pain,  and  there  is  an 
absence  of  tenderness  over  the  tendon  sheaths  and  the 
middle  palmar  and  thenar  spaces.  There  is  the  absence 
of  bulging  of  the  palm,  although  the  concavity  may  be 
lost.  The  patient  often  presents  great  prostration  (see 
pp.  324  and  329). 

The  superficial  type  lacks  the  great  swelling  of  the 


TENOSYNOVITIS  ,  61 

entire  hand  and  forearm.  We  receive  a  history  of  a 
slight  abravsion  or  injury  on  the  hand;  within  a  vshort 
time  the  patient  complains  of  all  the  vSymptoms  of  systemic 
absorption — headache,  thirst,  sleeplessness,  restlessness, 
and  fever.  On  examination  we  see  locally  an  area  of 
suffused  redness,  with  a  swelling  of  the  finger  which  is 
involved.  The  color  seldom  becomes  of  that  violaceous 
tint  seen  in  abscess  formation  or  the  pallor  which  succeeds 
it.  In  the  most  acute  types  there  may  be  little  or  no 
edema,  but  most  often  one  finds  a  considerable  edema 
most  marked  upon  the  back  of  the  hand.  The  swelling 
varies  with  the  site  of  the  invasion.  A  general  rule  may 
be  enunciated.  The  lymphatics  pursue  the  shortest  course 
to  the  back  of  the  hand.  For  example,  if  the  infection 
enters  at  the  distal  part  of  the  palm,  the  course  will  lie 
between  the  bases  of  the  fingers.  The  lymphatics  upon 
the  dorsum  will  show  up  as  bright  red  streaks  running 
up  the  arm.  Ordinarily  one  or  two  only  will  be  seen  upon 
the  back  of  the  forearm,  although  there  are  fifteen  to 
twenty  here.  The  lymphatics  from  the  little  finger  and 
ring  finger  pass  to  the  glands  in  the  epitrochlear  region, 
and  except  in  the  fulminating  type  these  will  be  found 
enlarged.  From  here  the  infection  is  carried  to  the 
axillary  region  and  thence  to  the  circulation.  The 
lymphatics  from  the  thumb  and  index  finger  will  be 
found  coursing  upon  the  back  and  outer  side  of  the  fore- 
arm and  wending  their  way  to  the  axillary  glands  without 
the  intervention  of  the  epitrochlear  glands  (see  p.  298). 

'       TENOSYNOVITIS. 

This  type  of  infection  is  much  more  difficult  to  diag- 
nosticate, and  the  surgeon  is  often  in  doubt  as  to  whether 
he  is  dealing  with  a  lymphangitis  or  tenosynovitis. 

The  disastrous  consequences  of  delayed  diagnosis  are 
so  well  known  that  the  surgeon  should  study  his  cases 
most  carefully,  since  in  nearly  every  case  an  early  diag- 
nosis can  be  made  and  the  function  of  the  hand  saved. 


62  DIAGXOSIS  L\  GENERAL 

The  three  cardinal  symptoms  and  signs  are: 

1.  Exquisite  tenderness  over  the  course  of  the  sheath, 
limited  to  the  sheath. 

2.  Flexion  of  the  finger. 

3.  Exquisite  pain  on  extending  the  finger,  most  marked 
at  the  proximal  end. 

These  symptoms  are  seen  to  be  only  a  difference  in 
degree  from  those  found  in  any  infection  of  the  hand, 
but  when  they  are  sought  for  in  an  intelligent  manner 
there  is  not  much  difficulty  in  differentiating  the  condi- 
tions. 

The  size  of  the  primary  wound  is  of  no  importance. 
The  tendon  sheath  may  become  infected  secondarily  to 
a  simple  pin  prick  or  an  extensive  wound.  One  finds 
only  the  cardinal  symptoms  I  have  mentioned,  and  in 
addition  he  may  notice  that  the  abutting  sides  of  the 
adjacent  fingers  are  swollen,  as  well  as  the  back  of  the 
hand.  The  whole  of  the  involved  finger  is  uniformly 
swollen.  The  whole  hand  is  slightly  tender  and  the 
fingers  are  slightly  flexed.  The  involuntary  expression 
of  pain  which  is  noticed  when  the  tendon  sheath  is  touched 
by  the  examining  finger  leaves  no  doubt  in  the  mind  of 
the  examiner  as  to  the  location  of  the  infection.  The 
greatest  amount  of  tenderness  is  generally  complained  of 
at  the  proximal  end  of  the  finger  sheath  in  the  palm  at  the 
metacarpo-phalangeal  articulation.  A  difference  is  readily 
seen  between  the  rigidity  in  the  infected  finger  and  the 
simple  flexion  in  the  adjacent  digits.  So  great  is  this 
difference  that  one  is  able  to  diagnosticate  an  extension 
into  the  palmar  sheath,  for  instance,  from  the  little  finger 
sheath,  since  the  character  of  the  flexion  changes  in  the 
other  fingers  to  the  more  rigid  noted  in  tendon-sheath 
infection.  The  spontaneous  pain,  which  was  at  first 
severe,  grows  less  as  the  edema  develops,  and  may  delude 
the  surgeon  into  believing  that  the  process  is  subsiding. 
The  arm  seems  "  to  fall  asleep,"  as  the  patient  expresses  it. 


TENOSYNOVITIS  '  g;} 

Paresthesia  with  creeping  and  itching  sensations  may  be 
present,  and,  especially  after  rupture  of  the  sheath,  the 
tenderness  may  subside  to  a  considerable  degree,  leading 
the  surgeon  to  an  early  erroneous  conclusion. 

An  infection  of  the  sheath  of  the  tendon  in  the  little 
finger  may  be  localized  to  the  finger.  Extensions  to 
other  areas  are  possible,  however.  The  following  are 
the  most  common:  (i)  The  ulnar  bursa;  (2)  the  radial 
bursa;  (3)  the  forearm;  (4)  fascial  spaces  in  the  hand: 
{a)  middle  palmar  space,  (Z>)  lumbrical  space;  (5)  osseous 
involvement,  middle  phalanx;  (6)  joints,  proximal  inter- 
phalangeal,  wrist;  (7)  rupture  to  the  surface. 

Extension  to  the  ulnar  bursa  is  often  difficult  to  diag-  >: 
nosticate.  It  is  marked  by  the  development  of  edema 
in  the  hand,  especially  upon  the  dorsum.  A  general 
fulness  in  the  palm  is  seen,  but  the  palmar  concavity  is. 
still  to  be  found.  On  the  flexor  surface  the  greatest 
swelling  is  found  just  proximal  to  the  annular  ligament. 
This  is  not  necessarily  due  to  the  rupture  of  the  sheath 
here,  but  to  the  looseness  of  the  tissues,  which  permits  of 
distention.  This  swelling  is  accentuated  by  the  non- 
distensible  annular  ligament  distal  to  it.  The  swelling 
in  the  palm  occurs  at  the  same  time,  but  is  not  so  con- 
spicuous, owing  to  the  palmar  fascia.  This  also  diffuses 
the  swelling  so  that  it  is  not  accurately  limited  by  the 
outline  of  the  ulnar  bursa.  Moreover,  the  surrounding 
edema  tends  to  confuse  the  picture  (see  pp.  206  and  209). 

The  most  conspicuous  and  valuable  sign  is  the  extension 
of  the  exquisite  tenderness  to  the  area  involved.  It  should 
be  remembered  that  this  is  absent  after  a  few  days.  The 
wrist  becomes  fixed,  the  thumb  shows  tenderness  to 
pressure,  and  particularly  on  passive  movements  is  the 
sensitiveness  noted.  It  is  seen  readily  of  how  much 
importance  the  latter  symptom  is  in  diagnosticating  an 
extension  to  the  ulnar  bursa  from  the  little  finger.  We 
note  that  while  at  first  the  symptoms  are  limited  to  the 


64  DIAGXOSIS  IX  GENERAL 

little  finger  and  slight  c  langes  in  the  ring  finger,  because 
of  its  juxtaposition,  all  at  once  the  thumb  begins  to  show 
the  characteristic  signs  while  the  index  and  middle  fingers 
remain  unchanged  except  for  the  increase  of  pain  on  pas- 
sive extension  explained  above.  This  sensitiveness  of  the 
thumb  may  be  due  either  to  the  juxtaposition  of  the  sacs, 
or  to  a  real  extension  into  its  sheath.  At  first  there  may 
be  a  diffuse  redness  of  the  palm  and  dorsum,  but  it 
rapidly  gives  place  to  a  whitish  or  even  cyanotic  hue. 
Above  the  wrist,  however,  the  tissue  generally  take  on 
a  marked  red  color,  which  later  becomes  violaceous. 

Extension  to  the  radial  bursa  is  diagnosticated  as 
following  an  ulnar  bursitis  by  the  increased  swelling 
and  tenderness  in  the  thenar  eminence  and  along  the 
sheath.  The  tumefaction  of  the  thenar  area  is  not  that 
of  abscess  in  the  thenar  space  (see  p.  216). 

The  temperature  and  pulse  may  not  be  of  any  diagnostic 
importance.  Ordinarily,  after  the  infection  has  lasted  a 
few  days  and  the  walling-off  process  has  begun,  the 
temperature  is  that  of  the  local  accumulations  of  pus  and 
varies  with  the  freedom  of  drainage.  The  first  few  days, 
however,  the  systemic  absorption  bears  no  relation  to  the 
abscess  formation  and  cannot  be  relied  upon  for  diagnostic 
purposes. 

From  the  bursa  various  extensions  frequently  take§ 
place  into  the  fascial  spaces  of  the  hand  and  forearm. 
The  symptoms  and  signs  of  this  extension  will  be  taken  up 
under  the  head  of  " Fascial-space  Infection"  {inde  infra; 
see  also  p.  204). 

Involvement  of  the  index,  middle,  and  ring  fingers 
presents  the  same  signs  as  the  little  finger.  The  only 
difference  is  that  here  the  paths  of  extension  are  different. 
Besides  the  extension  to  the  surface  at  the  proximal  end, 
involvement  of  the  middle  phalanx  and  the  proximal 
interphalangeal  joint,  the  finger  may  show  extension  to 
the  lumbrical  space  on  either  side,  and  from  here  involve 
the  adjacent  tendon  (see  p.  208). 


FASCIAL-SPACE  INFECTION  65 

Diagnosis  of  extension  from  a  tenosynovitis  of  the 
thumb  into  the  radial  bursa  and  then  into  the  ulnar 
bursa  is  more  difficult.  For  the  diagnosis  of  extension  to 
the  radial  bursa  we  must  depend  upon  the  extension  of 
the  tenderness  to  the  area  over  its  distribution  and  the 
tenderness  above  the  anterior  annular  ligament.  When 
the  extension  has  proceeded  over  into  the  ulnar  bursa, 
the  diagnosis  is  easier,  since  all  of  the  fingers  become 
painful  to  passive  extension,  most  markedly  the  little 
finger,  with  tenderness  over  the  area  of  the  ulnar  bursa 
particularly  at  the  junction  of  the  middle  flexion  crease 
of  the  palm  with  the  hypothenar  eminence  (see  p.  213). 

The  pus  from  the  radial  bursa  frequently  rupture  .into~~ 
the  tissues  of  the  forearm,  and  then  the  pus  lies  under  the 
flexor  profundus  tendons  just  as  in  rupture  of  the  ulnar 
bursa  (see  p.  152). 

FASCIAL-SPACE  INFECTION. 

Pus  may  be  found  in  various  spaces  in  the  hand  and 
forearm,  as  I  have  already  pointed  out.  This  may  occur 
as  a  primary  infection  or  secondary  to  lymphatic  or 
tendon-sheath  infection,  especially  the  latter.  I  have 
demonstrated  by  injection  and  serial  sections  the  spaces 
in  which  such  accumulations  can  take  place.  These  well- 
defined  spaces  are  five  in  number: 

1.  Middle  palmar  space. 

2.  Thenar  space. 

3.  Hypothenar  space. 

4.  Dorsal  subcutaneous  space. 

5.  Dorsal  subaponeurotic  space. 

The  thenar  and  middle  palmar  spaces  are  by  far  the 
most  important  and  most  frequently  involved  in  the  hand. 

The  forearm  has  certain  spaces  which  are  likely  to 

become  infected.     Briefly,  it  can  be  stated  that  pus  which 

has  extended  from  the  hand  to  the  forearm  always  lies 

under  the  flexor  profundus,  upon  the  pronator  quadratus 

5 


66  DIAGNOSIS  IX  GENERAL 

and  intermuscular  septum.  It  passes  upward,  following 
the  ulnar  artery,  going  as  high  as  the  elbow  (see  p.  157). 

Now,  how  shall  we  diagnosticate  an  invcjlvement  of 
these  various  spaces?  First,  upon  the  possibility  of 
extension  from  other  foci.  The  middle  palmar  space 
would  receive  infection  by  extension  from  the  middle 
finger,  ring  finger,  little  finger,  also  from  the  ulnar  bursa 
and  localized  infections  in  the  lumbrical  canals  between 
the  heads  of  the  metacarpals.  Again,  it  may  be  involved 
by  direct  implantation  or  through  osteomyelitis  of  the 
middle  and  ring  metacarpals.  It  is  possible  for  a  thenar 
space  abscess  to  rupture  into  the  middle  palmar  space 
(pp.  164  and  218). 

The  thenar  space  might  receive  the  infection  from  the 
index  finger  or  thumb,  or  by  direct  implantation,  or  by 
osteomyelitis  of  the  index  or  thumb  metacarpals,  and 
finally  it  would  be  possible  for  the  space  to  become 
involved  secondarily  to  the  middle  palmar  space  (see 
pp.  165  and  218). 

The  forearm  may  be  involved  by  rupture  from  either 
the  ulnar  or  radial  bursa  (see  pp.  152  and  396).  The 
source  of  the  involvement  of  the  other  spaces  can  be 
readily  surmised  (see  pp.  164  and  216). 

When  the  middle  palmar  space  is  involved  we  notice 
that  whereas  earlier  there  had  been  a  fulness  in  the 
palm  without  loss  of  the  concavity,  now  the  concavity 
begins  to  be  lost,  and  as  the  process  becomes  marked, 
a  slight  bulging  of  the  palm  is  noticeable  in  spite  of  the 
palmar  fascia.  The  correlation  of  this  with  tenderness  is 
of  especial  value.  Early,  before  the  swelling  becomes 
marked,  the  tenderness  is  exquisite  and  limited  by  the 
outlines  of  the  middle  palmar  space;  but  as  the  swelling 
increases,  the  tenderness  and  especially  the  spontaneous 
pain  grow  less.  There  is  generally  more  or  less  extension 
along  the  lumbrical  canals,  so  that  the  swelling  of  the  area 
between  the  heads  of  the  metacarpals  adds  to  the  general 


i 


FASCIA L-SPA^E  IXFECTION  '  07 

picture.  The  area  may  be  red,  but  generally  it  is  pallid. 
With  this  there  is  found  the  flexion  of  the  fingers  due  to  the 
juxtaposition  of  the  tendons  to  this  area.  They  are  held 
rigidly  flexed,  decreasing  in  rigidity  from  the  little  finger 
to  the  index  finger.  The  latter  may  have  considerable 
voluntary  motion.  If  the  pus  has  extended  along  the 
lumbrical  canals  to  the  base  of  the  fingers,  there  may  be 
swelling  and  induration  in  the  loose  tissue  of  the  web,  and 
an  accumulation  of  pus  may  be  found  to  have  extended  to 
the  dorsum  between  the  bases  of  the  proximal  phalanges. 
The  relation  of  the  swelling  in  the  ^ftm  to  that  in  the 
thenar  area  is  of  great  importance,  In  involvement  of 
the  middle  palmar  space  there  is  an  associated  swelling 
of  the  thenar  space  of  almost  the  same  degree  as  that  of 
the  middle  palmar  spa^fe,  but  this  is  due  to  edema  (see 
pp.  217  and  224).  When  the  thenar  space  becomes 
involved  the  swelling  is  out  of  all  proportion  to  that  of 
the  palm  if  it  be  involved.  There  is  the  induration  of 
infection  rather  than  the  softness  of  edema.  The  thenar 
space  will  look  as  if  a  balloon  had  been  inserted  into  the 
area  and  blown  up  to  its  full  capacity.  I  know  of  no 
clinical  picture  in  surgery  that  is  more  characteristic  than 
this  of  thenar-space  infection,  and  having  once  seen  it 
one  cannot  forget  it.  Besides  the  ballooning  out  of  the 
thenar  area,  the  metacarpal  of  the  thumb  is  pushed  away 
from  the- hand;  the  flexion  of  the  distal  phalanx  becomes 
more  marked,  though  lacking  the  rigidity  found  in  involve- 
ment of  the  tendon  sheath  of  the  flexor  longus  pollicis. 
This  infection  of  the  thenar  space  may  be  primary  and 
isolated  or  secondary  to  a  middle  palmar  infection  (see 
pp.  165  and  2,18). 

The  edema  upon  the  back  of  the  hand  is  always  present 
and  the  swelling  much'greater,  of  course,  than  in  the  palm, 
even  though  that  be  the  site  of  the  pus.  It  is  extremely 
uncommon  to  find  any  pus  upon  the  dorsum  unless  there 


68  DIAGNOSIS  I^  GENERAL 

has  been  a  lymphatic  infection  or  the  pus  has  extended, 
as  already  described,  between  the  metacarpals  of  the  index 
finger  and  thumb  from  the  thenar  space,  or  between  the 
heads  of  the  proximal  phalanges.  We  should  bear  in 
mind  that  edema  gives  rise  to  a  soft  pitting,  while  if  pus 
be  present  induration  can  always  be  felt.  If  this  fact  is 
borne  in  mind  many  embarrassing  mistakes  will  be 
avoided.  I  think  that  in  three-fourths  of  the  hands  I  see 
in  which  treatment  has  been  instituted  a  number  of 
unnecessary  and  improper  incisions  are  found  upon  the 
dorsum  (Fig.  90).-' 

The  forearm  may  be  involved  from  a  tenosynovitis  of 
the  ulnar  or  radial  bursa.  As  has  been  pointed  out,  the 
pus  in  these  cases  passes  between  the  pronator  quadratus 
and  the  flexor  profundus  to  the  area  between  the  latter 
and  the  interosseous  membrane,  and  at  about  the  middle 
of  the  area  it  passes  more  superficially  and  to  the  ulnar 
side  along  the  ulnar  artery  and  nerve.  This  extension  is 
characterized  by  a  brawny  induration  that  should  not  be 
confused  with  the  softness  of  an  edema.  No  fluctuation 
should  be  expected,  since  the  accumulation  lies  too  deeply. 
If  the  primary  source  is  the  ulnar  or  radial  bursa,  this 
extension  is  marked  by  the  loss  of  the  relative  swelling 
immediately  above  the  annular  ligament,  due  to  the 
distended  upper  end  of  the  sheath.  This  swelling  is  not 
any  less,  but  that  of  the  arm  is  greater.  The  tenderness 
may  become  less,  so  it  cannot  be  depended  upon  as  a 
symptom.  The  redness  is  generally  greater,  and  spon- 
taneous pain,  while  at  first  marked,  rapidly  subsides. 
At  this  time  some  pus  may  accumulate  subcutaneously 
above  the  wrist  and  lead  to  the  supposition  that  there  is 
no  pus  under  the  tendons.  Thus  valuable  time  is  lost 
(see  pp.  208  and  396). 

Involvement   of   the   hypothenar  space   can   often   be 
prognosticated    from    the    site    of    the    primary    injury, 


FASCIAL-SPACE  INFECTION      ,  69 

♦ 
while  the  relative  lack  of  swelliiiii"  in  the  palm  and  fin.uers, 

with  absence  of  involvement  of  the  tendons,  combined 
with  the  ordinary  symptoms  of  abscess,  leads  us  to  an 
easy  diagnosis.  Fortunately,  the  hypothenar  area  is  so 
separated  from  the  remainder  of  the  hand  that  it  is  not 
involved  secondarily  to  palmar  infection  (see  \)\).  145 
and  178). 

An  infection  localized  upon  the  dorsum  under  the  sub- 
aponeurotic fascia  to  the  exclusion  of  the  subcutaneous 
tissue  may  be  difficult  of  differential  diagnosis.  However, 
we  are  aided  materially  if  we  remember  the  character  of 
the  primary  injury,  the  methods  of  extension  to  this 
space  already  mentioned,  and  the  local  evidences  of 
infection  upon  the  dorsum,  with  the  pitting  edema  of  the 
subcutaneous  tissue,  yet  lacking  the  brawny  induration 
and  localized  tenderness  of  a  subcutaneous  abscess  (see 
pp.  145  and  178). 

We  may  be  in  doubt  as  to  whether  we  are  dealing 
with  a  tenosynovitis  of  the  dorsal  bursae  or  a  rheumatism 
of  the  wrist.  In  those  cases  presenting  an  apparently 
spontaneous  development  of  an  inflammation  at  the  wrist, 
the  diagnosis  may  be  most  difficult  in  spite  of  the  ease 
with  which  a  theoretical  differential  diagnosis  is  made. 
Here  again,  however,  the  localized  tenderness  over  the 
sheath  and  pain  on  movement  of  the  fingers  are  of  the 
greatest  importance.  In  a  rheumatism  there  is  as  much 
pain  on  the  volar  as  on  the  dorsal  surface  and  other  joints 
may  be  involved.  The  presence  of  a  gonorrhea  does  not 
aid  us  materially  since  either  condition  may  follow.  In  one 
case  it  was  difficult  to  determine  whether  the  patient  was 
suffering  from  a  gonorrheal  rheumatism  of  the  proximal 
interphalangeal  joint  of  a  finger  or  a  gonorrheal  teno- 
synovitis with  secondary  involvement  of  the  joint.  The 
latter  assumption  was  later  found  to  be  the  condition 
present. 


70  DIAGNOSIS  IN  GENERAL 

DIAGNOSIS    OF    EXTENSIONS    FROM    VARIOUS    SITES. 

The  diagnosis  of  the  extensions  from  various  sites  is 
of  the  greatest  importance  from  a  therapeutic  standpoint. 
I  have  worked  out  these  possibilities  by  both  experimental 
and  clinical  observations.  The  present  chapter  is  too 
brief  to  allow  a  full  discussion.  I  shall,  however,  append 
a  tabulation,  with  references  attached,  denoting  where  a 
complete  discussion  of  each  subject  can  be  found. 

If  the  infection  originates  in  the  thumb,  for  possible 
extensions  see  p.  i88. 

If  the  infection  originates  in  the  index  finger,  for 
possible  extensions  see  p.  i8o. 

If  the  infection  originates  in  the  middle  finger,  for 
possible  extensions  see  p.  189. 

If  the  infection  originates  in  the  ring  finger,  for  possible 
extensions  see  p.  191. 

If  the  infection  originates  in  the  little  finger,  for  possible 
extensions  see  p.  192. 

If  the  palmar  space  is  involved,  for  possible  extensions 
see  pp.  141  and  171. 

If  the  thenar  space  is  involved,  for  possible  extensions 
see  pp.  144  and  176. 

If  the  forearm  is  involved,  for  possible  extensions  see 
pp.  157  and  396. 

If  the  ulnar  bursa  is  involved,  for  possible  extensions 
see  pp.  119  and  204. 

If  the  radial  bursa  is  involved,  for  possible  extensions 
see  pp.  123  and  213. 


r 


CHAPTER   VI. 
GENEFL^L  PRINCIPLP:S  OF  TREATMENT. 

It  is  not  the  intention  here  to  discuss  in  detail  the 
treatment  of  the  various  types  of  infections.  Specific 
directions  for  deahng  with  individual  cases  will  be  dis- 
cussed in  the  chapters  devoted  to  the  different  types. 
It  is  proper,  however,  to  deal  with  the  general  principles 
underlying  the  various  procedures  which  might  be 
scattered  in  the  succeeding  chapters. 

The  early  treatment  in  any  case  has  for  its  purpose  the 
walling  oft'  of  infection,  or  its  removal  by  phagocytic 
action. 

Prophylaxis. — Great  care  should  be  used  in  the 
preliminary  treatment  of  minor  as  well  as  major  injuries, 
especially  in  factories.  If  the  foremen  were  taught  to 
insist  upon  each  man  taking  proper  precautions,  many 
hands  would  be  saved.  Every  man  injured  should  apply 
at  once  to  the  foreman,  who  should  pour  iodine  into  the 
wound  and  apply  a  light  sterile  bandage  for  twenty-fcur 
hours.  There  should  be  no  preliminary  scrubbing  or 
washing.  This  system  could  be  instituted  in  all  factories 
with  little  difficulty.  (See:  Chapter  XXV.  Hand  Infec- 
tions among  Employees.) 

Rest. — Rest  is  one  of  the  essential  factors,  at  least  in 
a  negative  sense.  The  extremity  affected  should  always 
be  so  fixed  that  movement,  either  of  the  whole  or  muscular 
action  of  a  part,  is  impossible,  since  it  is  well  known  that 
lymphatic  streams  are  aided  materially  in  their  return 
flow  by  muscular  action.  It  will  undoubtedly  relieve  the 
patient  somewhat  of  the  throbbing  pain  to  have  the  hand 
elevated  after  the  von  Volkmann  method,  but  beyond  that 

(71) 


72  GENERAL  PRINCIPLES  OF  TREATMENT 

I  cannot  feci  that  the  procedure  is  of  i;reat  therajjcutic 
value. 

Positive  factors  designed  to  increase  phagocytic  action 
are  still  subject  to  discussion,  in  spite  of  the  extensive 
contributions  in  support  of  this  or  that  procedure.  They 
may  be  classified  as  systemic  and  local.  The  local  again 
are  divided  into  the  results  of  active  hyperemia  and  of 
passive  hyperemia. 

Drugs. — The  systemic  use  of  drugs,  such  as  nucleic 
acid,  etc.,  to  increase  leukocytosis,  has  never  been 
followed  by  such  marked  and  positive  results  as  to 
prove  beyond  question  the  advisability  of  their  use, 
and  all,  so  far  as  known,  may  ultimately  be  discarded, 
as  was  turpentine,  which  preceded  them.  They  have 
never  given  any  results  in  my  hands.  We  are  not  now 
discussing  the  applicability  of  drugs  and  sera  in  systemic 
infections.  That  will  be  taken  up  under  that  heading 
later  (see  pp.  351  and  352). 

Passive  Hyperemia. — ^Among  the  local  procedures 
those  producing  passive  hyperemia  (Bier)  have  received 
the  greatest  attention  in  later  years.  While  much  of  an 
enthusiastic  nature  has  been  written  in  favor  of  this 
method,  it  is  probable  that  the  American  surgeons  have 
not  secured  the  results  claimed  for  it  by  its  German 
supporters.  It  is  not  the  province  of  such  a  contribution 
as  this  to  review  the  subject,  with  a  discussion  of  the 
various  theories  as  to  the  changes  in  the  blood;  the 
lessened  resistance  as  claimed  by  some  and  the  raised 
opsonic  index  as  maintained  by  others.  My  personal 
opinion  has  become  quite  settled  as  to  its  value  in  acute 
infections.  I  haVe  found  its  chief  value  in  three  condi- 
tions: 

I.  In  those  conditions  in  which  I  wish  to  prevent  the 
rapid  absorption  of  toxins  into  the  circulating  blood,  as, 
for  instance,  in  an  acute  lymphangitis  (see  pp.  348  and 
349),  or  immediately  after  incising  virulent  abscesses  of 


HOT  MOIST  DRESSINGS  -  73 

the  hand  and  arm  where  a  marked  constriction  will 
reverse  the  lymph  stream  and  tend  to  wash  the  toxins  out 
into  the  wound,  preventing  absorption  (see  pp.  226  and 
272). 

2.  In  those  cases  in  which  the  process  has  become 
semichronic  with  a  low  grade  of  infection  (see  \)\).  227 
and  447). 

Beyond  these  conditions  I  must  say  I  look  upon  it  as 
a  possible  adjuvant  in  the  treatment,  but  never  as  the 
primary  factor.  It  follows,  therefore,  that  early  in  the 
course  of  an  infection,  if  we  suspect  the  process  to  be 
particularly  virulent,  a  bandage  may  be  applied  to  the 
arm  after  the  method  described  on  pp.  226  and  348. 
Any  other  method  is  painful  and  may  even  be  harmful. 
In  the  ordinary  cases  I  have  contented  myself  with  other 
means,  namely,  hot,  moist  dressings,  the  use  of  which  it 
would  appear  rests  upon  a  more  rational  basis.  Klapp 
has  emphasized  the  value  of  suction  cups  used  over  a 
localized  infection.  He  has  devised  various  types  to  fit 
various  areas.  Their  value  in  certain  conditions  cannot 
be  gainsaid,  particularly  in  those  cases  which  would  be 
classified  in  the  second  and  third  groups  above. 

Hot  Moist  Dressings. — These  are  in  common  use 
by  all,  and  have  proved  beneficial  in  many  cases.  The 
most  common  form  in  which  they  are  applied  is  that 
of  the  saturated  hot  boric  acid  solution,  although  many 
other  medicaments  are  employed,  such  as  potassium 
permanganate,  alcohol,  bichloride,  etc.  The  solution  of 
hot  boric  acid,  in  my  opinion,  depends  for  its  efficiency 
largely  upoii  the  moist  heat,  although  scientific  evidence 
is  not  wanting  that  its  chemical  action  may  be  of  some 
value.  In  this  connection  Dr.  E.  H.  Oschsner  reports 
that  Professor  Kalflenberg,  at  the  University  of  Wisconsin, 
conducted  a  series  of  examinations  demonstrating  the 
presence  of  a  small  amount  of  boric  acid — o.oi  to  0.03  per 
cent. — in  urine  voided  after  hot  applications  of  a  saturated 


74  GENERAL  PRIXCIPLES  OF  T  RE  ATM  EXT 

solution  of  boric  acid  in  water,  3  parts,  and  95  per  cent. 
alcohol,  I  part.  This  is  not  the  occasion  to  discuss  the 
question  as  to  the  bactericidal  effect  of  boric  acid,  especi- 
ally in  small  percentages.  Other  investigators  have 
maintained  that  a  large  percentage  is  found  in  the  skin 
and  subcutaneous  tissue.  The  dressings  may  be  applied 
as  follows:  The  saturated  solution  is  boiled  and  then  set 
aside,  and,  as  it  is  desired,  it  is  heated  to  as  great  a  heat 
as  can  be  borne  by  the  bare  forearm  of  the  attendant. 
Greater  heat,  as  demanded  by  some,  is  not  needful.  The 
patient  should  not  be  left  to  decide  "if  he  can  stand  it," 
since  the  infected  hand  is  often  very  insensitive  to  super- 
ficial pain,  and  the  inadvertent  application  of  the  excessive 
heat  may  lead  to  blisters  which  will  be  annoying  and  pro- 
long convalescence.  After  the  desired  temperature  is 
secured  a  sterile  towel  is  unfolded,  the  dressings  are 
dropped  into  it,  and  it  is  then  immersed  at  its  middle  in 
the  water.  The  dressings  are  wrung  dr>^  by  turning  the 
two  dry  ends  in  opposite  directions,  thus  securing  the 
dressings  properly  saturated  and  wrung  out,  but  still 
sterile.  The  dressing  is  now  applied  widely,  covering  the 
entire  infected  area,  going  proximally  some  inches.  Fear 
rather  that  your  dressing  may  be  too  small  than  too 
voluminous.  The  whole  is  covered  by  some  impervious 
material,  such  as  paper  saturated  with  paraffin  or  sheet 
gutta-percha.  This  should  be  covered  by  a  layer  of  cotton 
followed  by  a  bandage.  Provision  should  be  made  at  the 
time  of  dressing  for  subsequent  applications  of  the  solution 
by  making  a  hole  or  two  through  the  outside  covering 
down  to  the  dressing.  Through  these  openings  the  boric 
acid  solution  should  be  poured  every  two  hours,  and  the 
hand  dressed  as  frequently  as  necessary. 

Too  often  we  see  the  hot  boric  acid  continued  for  several 
days.  It  is  not  only  useless  but  harmful  to  continue  this 
treatment  after  the  process  is  once  under  control,  since 
it  tends  to  favor  congestion  and  round-celled  exudation. 


HYPERTONIC  SALT  SOLUTION     '  75 

which  if  long  continued  produces  a  soggy,  infiltrated  hand, 
in  which  absorption  is  slow,  and  as  a  consccjuence  the 
ravages  of  the  disease  are  slowly  repaired  and  fibrinous 
ankylosis  of  joints,  adhesion  of  the  tendons,  shrinking  of 
muscles,  and  fibrosis  in  all  the  various  structures  are 
favored . 

As  soon  as  the  process  has  subsided  it  may  be  treated 
in  various  ways,  according  to  the  condition.  In  the 
presence  of  congestion,  a  dressing  saturated  with  a  weak 
solution  of  alcohol  or  equal  parts  of  alcohol  and  glycerin 
will  aid  in  the  dehydration.  If  there  is  a  foul  discharge, 
a  I  to  2000  potassium  permanganate  dressing  is  advisable. 
If  there  are  many  raw  surfaces  requiring  dressing,  the 
gauze  may  be  saturated  with  vaseline,  which  permits  of 
painless  dressing  and  does  not  retard  drainage.  Against 
alcohol  may  be  urged  with  justice  its  inflammability,  so 
that  it  should  always  be  used  with  care.  One  case  came 
to  my  notice  in  which  the  patient  was  severely  burned 
through  its  use. 

Hypertonic  Salt  Solution. — Wright  has  suggested 
the  use  of  a  5  per  cent,  solution  of  sodium  chloride 
in  suppurating  wounds.  Gauze  wicks  are  saturated  in 
this  solution,  the  wicks  being  carried  out  into  dressings 
which  have  been  saturated  with  the  same  solution.  More- 
over, in  the  end  of  the  wicks  he  places  tablets  of  sodium 
chloride  with  the  idea  of  keeping  up  the  saturation. 
Although  sodium  chloride  in  such  strength  will  prevent 
coagulation  in  the  presence  of  pus,  it  is  better  to  add  a 
0.5  per  cent,  solution  of  sodium  citrate.  This  prevents 
the  clogging  of  the  meshes  of  the  gauze  with  the  coagulated 
serum. 

It  is  evident  that  this  solution  should  not  be  used  in 
those  cases  in  which  there  is  danger  of  hemorrhage,  but 
it  may  be  a  valuable  adjuvant  in  deep-seated  wounds  and 
in  those  in  which  we  wish  to  reverse  the  l^'mphatic  drain- 
age and  carr^'  the  bacteria  from  the  superficial  lesions  of 
the  wound. 


76  GENERAL  PRTXCTPLES  OF  TREATMENT 

In  extensively  infected  wounds  where  there  is  much 
necrotic  tissue  Dakin's  solution  properly  applied  is  of 
material  benefit. 

Prophylactic  Incision. — One  constantly  meets  cases 
in  which  the  patient  has  been  subjected  to  incision  at 
some  swollen  or  tender  area,  under  the  assumption  that 
if  there  is  not  pus  there  the  "drainage  will  do  good  any- 
way." Such  incisions  are  always  ill-advised,  since  they 
nearly  always  do  more  harm  than  good.  A  general  rule 
should  be  laid  down  not  to  incise  unless  the  surgeon  has 
an  accurate  appreciation  of  the  condition  and  an  absolute 
diagnosis  has  been  made.  In  general  one  may  say  that 
incision  in  lymphatic  infections  should  be  made  as  a  last 
resort  or  because  of  secondary  complications  (see  pp.  349 
and  355).  Tenosynovitis  should  be  treated  by  drainage 
as  soon  as  a  probable  diagnosis  is  made  (see  pp.  246  and 
248).  Abscesses  of  the  fascial  spaces  are  never  so  urgent 
as  to  demand  operation  before  one  is  sure  of  the  diagnosis. 
These  rules  are  urged  most  emphatically,  since  I  see  in 
consultation  fully  as  many  cases  in  which  the  incision 
made  has  been  ill-advised  or  unnecessary  as  I  do  those  in 
which  further  surgical  work  is  indicated. 

When  incision  has  been  decided  upon  certain  rules  are 
imperative  in  the  severe  case.  The  operation  should  be 
done  in  a  bloodless  field.  A  Martin  bandage  applied  from 
the  elbow  to  the  shoulder  is  to  be  preferred.  After  the 
operation  is  concluded  the  bandage  is  loosened  slightly 
just  enough  to  allow  circulation,  but  still  tight  enough 
to  prevent  rapid  absorption.  In  fact,  I  attempt  to  pro- 
duce a  Bier's  hyperemia.  This  is  done  with  the  hope  of 
preventing  the  rapid  absorption  of  toxins.  In  a  patient 
who  is  severely  ill  such  rapid  absorption  may  take  place 
as  to  overwhelm  the  system  before  it  has  an  opportunity 
to  develop  antitoxins  or  wall  off  the  infection;  while  if  the 
bandage  is  removed  through  the  course  of  twenty-four 
hours  the  system  may  have  an  opportunity  to  develop 


DRAINAGE  '  77 

antitoxins  and  ward  off  by  leukocytic  action  a  systemic 
infection  that  might  ultimately  lead  to  death.  Again, 
the  patient  should  always  be  anesthetized.  Nitrous 
oxide  is  the  anesthetic  of  choice,  owing  to  its  non-toxic 
action.  This  gives  time  for  carefully  placed  and  adequate 
incisions.  The  surgeon  should  always  convince  himself 
before  allowing  the  patient  to  awaken  that  he  has  done  the 
work  thoroughly  so  that  the  operation  will  not  have  to  be 
repeated  upon  subsequent  days.  This  cannot  be  done 
under  local  anesthesia.  Moreover,  the  hypodermic  injec- 
tion of  tissue  about  an  infected  area  cannot  be  done 
without  danger  of  causing  a  spread  either  locally  or 
systematically. 

Drainage. — Drainage  of  wounds  by  means  of  gauze, 
tubes,  etc.,  is  not  of  the  importance  attributed  to  it  by 
some.  The  essential  factor  is  to  make  the  incision  at  the 
right  place  and  of  adequate  size.  If  this  is  done,  drainage 
strips  will  be  not  only  unnecessary  after  the  first  forty- 
eight  hours,  but  often  positively  detrimental  to  recovery. 
After  incision  it  is  my  custom  to  use  either  plain  gauze, 
gauze  saturated  with  vaseline,  or  rubber  strips.  The 
former  is  used  only  when  there  is  venous  oozing  and  we 
desire  to  stop  it  by  favoring  coagulation.  We  must  never 
expect  it  to  do  more  than  this,  and  keep  the  edges  of  the 
wound  separated,  for  the  plain  gauze  mesh  is  soon  filled 
with  pus  and  coagulated  serum,  which  acts  as  an  effectual 
bar  to  drainage.  Where  there  is  no  bleeding,  gauze 
strips  thoroughly  saturated  with  vaseline  or  rubber  strips 
are  used.  These  secure  adequate  drainage,  and  can  be 
removed  without  pain.  They  are  left  in  for  twenty-four 
to  forty-eight  hours;  if  left  in  longer  they  prolong  the 
suppuration.  It  has  happened  to  every  surgeon  to  see 
cases  in  which  the  wound  has  been  kept  open  for  weeks 
by  ill-advised  drainage  material.  Except  where  the 
Carrel-Dakin  method  is  used  rubber  tubes  are  never  used, 
since  they  favor  tissue  necrosis  and  are  not  any  more 


78  GENERAL  PRINCIPLES  OF  TREATMENT 

satisfactory  for  drainage  than  rubber  strips.  Spring 
separators  made  of  wire  may  be  used  to  keep  the  wound 
open. 

It  has  been  suggested  by  some  that  in  order  to  prevent 
rapid  absorption  and  danger  of  generahzed  infection,  it 
would  be  advisable  to  open  abscesses  by  the  cautery,  and 
again  others  have  suggested  painting  the  cut  edges  with 
some  solution  of  iodine.  The  advisability  of  this  pro- 
cedure is  open  to  discussion,  since  it  surely  should  not  be 
used  unless  the  abscess  is  thoroughly  walled  off,  in  which 
case  it  is  possible  to  conceive  of  this  procedure  being 
pathologically  sound.  In  a  majority  of  cases,  however, 
bacteria  and  toxins  in  the  wall  are  thus  sealed  up  and 
serum  drainage  by  the  method  I  have  suggested  is  pre- 
vented (see  pp.  227  and  2^2).  Thus  the  patient  is  in 
greater  danger  of  systemic  infection  or  prolonged  local 
disturbance.  It  is  my  personal  belief  that  any  procedure 
which  impairs  the  vitality  of  tissue-cell  life,  thus  reducing 
its  resistance  and  reparative  powers,  will  be  discarded  in 
the  end. 

The  common  habit  of  pressing  and  squeezing  wounds 
with  the  purpose  of  forcing  out  the  contained  pus  cannot 
be  too  severely  condemned.  It  is  both  unnecessary  and 
harmful.  If  adequate  incision  is  made,  the  pus  free  in 
the  abscess  will  drain  out,  and  if  it  is  in  the  layers  of 
fascia  adjacent  to  the  wound,  pressure  is  just  as  likely  to 
force  it  farther  into  the  tissue  as  into  the  abscess  cavity. 
If  the  opening  is  small  and.  drainage  inadequate  because 
of  the  thickness  of  the  pus,  the  wound  should  be  opened 
more  widely.  If  the  opening  is  plugged  by  seminecrotic 
connective  tissue,  it  may  be  removed  by  the  forceps, 
never  with  a  sharp  curette.  To  repeat,  the  pressure  and 
squeezing  tend  to  disseminate  the  infection  throughout 
the  surrounding  tissue  and  even  produce  systemic  infec- 
tion or  dislodge  septic  thrombi. 

After  almost  all  incisions  in  virulent  cases  there  is  severe 


BAKING  IN  DRY,  HOT  AIR  79 

local  reaction,  causing  more  swelling  in  the  first  twenty- 
four  to  thirty-six  hours.  At  the  end  of  that  time,  if  the 
process  has  been  properly  drained,  the  swelling  and 
temperature  should  begin  to  subside. 

Stimulation  of  Excretion. — The  excretions  should 
be  stimulated,  particularly  by  the  introduction  of  large 
amounts  of  water  into  the  system.  This  may  be  done 
subcutaneously,  by  rectum,  or  by  mouth,  according  to 
the  conditions  to  be  met.  If  introduced  by  rectum, 
ordinary  tap  water  has  been  more  satisfactory  than 
normal  salt  solution  since  it  is  better  borne  by  the  patient 
and  relieves  his  thirst  more  quickly.  In  the  severe  toxe- 
mias I  also  use  peptonized  foods  for  the  reasons  enumer- 
ated later  (see  p.  351). 

Massage. — The  early  use  of  massage,  passive  and  active 
motion  is  one  of  the  essentials  in  the  production  of  func- 
tionating hands.  Its  use  is  particularly  urged  in  tendon- 
sheath  infection  (see  p.  275). 

Baking  in  Dry,  Hot  Air. — Auchincloss,  who  has 
made  an  extensive  study  of  infections  of  the  hand,  tells 
me  that  he  has  had  most  satisfactory  results  from  the 
use  of  baking  in  dry,  hot  air.  He  is  convinced  that  this 
gives  the  patient  much  comfort  and  adds  to  the  recovery 
after  hot  fomentations  in  the  acute  as  well  as  the  chronic 
cases.  The  idea  seems  to  be  perfectly  rational  and  I 
believe  will  be  a  distinct  addition  to  our  therapy  in  these 
cases. 


SECTION    I. 

THE  ANATOMY  OF  THE  HAND  AND  FOREARM, 
WITH  ESPECIAL  CONSIDERATION  OF  ITS  RELA- 
TION TO  INFECTIONS  OF  THE  SYNOVIAL 
SHEATHS  AND  FASCIAL  SPACES. 


CHAPTER  VII. 

METHODS  OF  STUDY  IN  GENERAL:  STUDY  OF 
SERIAL  CROSS-SECTIONS  OF  THE  HAND, 
WITH  PARTICULAR  RELATION  TO  THE 
FASCIAL  SPACES. 

L'PON  beginning  the  study  of  infections  of  the  hand  it 
was  reaHzed  immediately  that  our  general  knowledge 
of  the  anatomy  was  entirely  inadequate  when  we  came 
to  apply  it  to  specific  conditions.  The  first  problem, 
therefore,  with  which  we  had  to  deal  was  a  thorough 
study  of  the  anatomy  carried  out  entirely  in  relation  to 
this  question.  As  the  work  progressed,  the  reasons  for 
many  failures  in  diagnosis  and  treatment  were  seen.  We 
are  firmly  convinced  that  anyone  who  wishes  to  master 
the  proper  steps  in  diagnosis  and  treatment  must  follow 
step  by  step  the  unfolding  of  the  anatomical  picture  as  we 
shall  try  to  present  it  in  the  subsequent  pages.  It  will 
be  discussed  in  the  following  manner: 


METHODS   OF  STUDY  81 

Anatomy  of  the  Hand  and  Forearm,  with  Surgical 
Deductions. 

A.  Anatomy  of  the  hand. 

I.   Methods  of  study. 
II.  Study  of  serial  cross-sections,  with  particular 

relation  to  fascial  spaces. 
III.  Study  of  the  tendon  sheaths  in  general. 
\\.  Study  of  the  fascial  spaces  and  tendon  sheaths 

by  means  of  experimental  injections. 
V.  Study  of  .T-ray  pictures  of  injected  hands. 
VI.  Study  of  the  embryology. 

B.  Anatomy  of  forearm. 

I.  Anatomy  in  general. 
II.  Study  of  serial  cross-sections. 
III.  Study  by  means  of  injection  of  the  connective- 
tissue  spaces. 

.  METHODS    OF    STLT)Y. 

I.  With  the  object  of  securing  a  tentative  picture 
of  the  spaces  and  their  relation  to  the  tendon  sheaths 
in  particular  and  other  structures  in  general,  a  freshly 
amputated  cadaver  hand  was  hardened  in  formalin 
and  cross-sections  made,  beginning  at  the  middle  joints 
of  the  fingers,  and  cutting  sections  about  one  centimeter 
in  width,  going  as  high  as  the  elbow.  The  fascial  layers 
were  then  teased  out  and  their  relations  to  the  muscles, 
bones,  tendons,  nerves,  and  bloodvessels  determined. 
The  prolongations  of  the  various  spaces  were  followed  up, 
each  space  and  each  tendon  sheath  being  followed  from 
one  section  to  another;  thus,  their  limitations  were 
determined  and  the  relation  of  the  various  adjacent 
structures  noted.  The  specimen  chosen  was  one  with  but 
little  fat  (Fig.  24). 

The  same  process  was  carried  out  in  a  fresh  cadaver 
hand  in  which  the  vessels  were  injected  and  the  sections 

6 


82 


METHODS  OF  STUDY  IN  GENERAL 


cut  while  the  hand  was  frozen.  Sections  were  made  of 
a  third  hand  at  right  angles  to  the  metacarpal  bone  of 
the  thumb,  since  it  was  found  that  the  findings  in  the 
thenar  area  were  somewhat  confusing.  This  hand  also 
was  frozen,  and,  like  the  first  and  second,  without  much 
fat.  By  these  sections  a  fairly  definite  idea  of  the  spaces 
was  secured. 


Fig.   24. — Drawing  made  from  specimen,  showing  sites  of  the  various  sections 
taken  through  the  hand. 

2.  To  corroborate  the  findings  above,  as  well  as  to 
determine  their  exact  limitations,  injections  were  made 
into  the  various  fascial  spaces,  by  various  channels, 
and  with  varying  degrees  of  force.  This  determined 
not  alone  the  positions  and  relations  of  the  pockets,  but 
also  by  what  channel  pus  could  reach  them  and  where 
it  would  extend  if  it  broke  through  the  walls  of  the 
closed  fascial  spaces.  By  this  we  also  determined  the 
course  pus  would  pursue  when  it  ruptured  from  the 
tendon  sheaths,  and  thus  fixed  the  relation  of  the  tendon- 
sheath  infections  to  fascial-space  infections.     The  findings 


METHODS  OF  STUDY  83 

were  very  uniform  and  satisfactory,  with  the  exception 
of  three  or  four  which  did  not  reach  the  spaces  intended. 
The  material  used  was  such  as  is  ordinarily  found  in  the 
dissecting  room;  hence,  while  the  part  was  always  well 
presersed,  in  some  cases  the  material  was  more  friable 
than  in  others,  and,  therefore,  rupture  from  the  space 
was  more  likely  to  occur.  However,  this  does  not 
interfere  with  the  deductions,  since  the  changes  present 
were,  in  a  measure,  comparable  to  those  found  in  inflam- 
matory' processes.  Moreover,  no  matter  whether  the 
tissue  was  fresh  or  preser\'ed  the  findings  were  the  same, 
so  we  may  feel  sure  that  the  results  are  to  be  depended 
upon. 

The  fascial  spaces  of  56  hands  and  forearms  were 
injected  from  ^'arious  sites  b}'  plaster  of  Paris,  which  had 
been  rubbed  up  with  glycerin  and  diluted  with  water. 
It  was  injected  b}'  means  of  a  hand  pump  through  a 
cannula,  which  was  inserted  at  various  points,  as  will  be 
noted  later.  As  the  hands  were  dissected,  the  location 
and  paths  of  extension  of  the  masses  were  noted.  In 
those  cases  injected  with  moderate  force  a  pressure  of  4 
to  8  pounds  was  used,  and  where  forcible  injection  is 
noted,  25  to  35  pounds. 

3.  Several  hands  were  injected  as  above,  except  that 
the  injection  mass  was  impregnated  with  red  lead.  X-ray 
pictures  were  taken.  This  showed  the  relation  of  the 
theoretical  pus  accumulations  to  the  bones  and  blood- 
vessels, the  latter  having  been  injected  with  the  same 
mass.  Again,  in  other  hands,  injections  of  various  spaces 
were  made,^  concomitant  with  injections  of  the  synovial 
sheaths,  to  show  their  relati:on  and  the  proper  site  for 
operations  designed  to  open  the  former  without  injure- 
to  the  latter. 

4.  After  this  work  had  been  done  a  study  of  the 
embryology  was  made,  with  a  view  of  determining 
whether   or   not    there    was    anv    relation    between    the 


84  METHODS  OF  STUDY  IN  GENERAL 

anatomical  peculiarities  of  the  spaces  and  the  embryo- 
logical  development. 

5.  The  clinical  cases  which  came  under  observation 
were  observed  very  carefully  to  see  if  the  real  pathology 
corresponded  with  the  anatomical  demonstration.  Bac- 
teriological studies  of  all  cases  were  made  that  we  might 
investigate  the  relation  between  the  variety  of  germs 
present  and  the  tendency  to  spread.  In  the  present 
edition  this  study  has  been  supplemented  by  the  observa- 
tions which  have  accumulated  during  the  twenty  years 
that  have  elapsed  since  this  study  began. 

A  STUDY  OF  SERIAL  CROSS-SECTIONS,  WITH  PARTICULAR 
RELATION  TO  THE  FASCIAL  SPACES. 

That  we  may  follow  the  study  of  the  serial  cross- 
sections  with  more  understanding,  the  following  facts 
should  be  noted:  It  is  known  that  five  spaces  may  be 
found  in  the  hand;  the  information  about  them,  however, 
has  been  very  indefinite.  The  result  of  our  study  shows 
that  upon  the  palmar  surface  we  have  three  distinct 
chambers,  not  communicating  in  any  way  with  each  other, 
and  to  these  are  given  the  names  thenar,  hypothenar, 
and  middle  palmar  spaces  respectively.  Certain  channels 
will  be  found  which  lead  directly  into  them.  Certain 
structures  along  which  pus  can  pass  will  be  noted  lying  in 
juxtaposition.  Again,  minor  anatomical  chambers  will 
be  noted;  these,  however,  need  little  or  no  consideration 
from  a  surgical  standpoint,  since  they  are  unimportant, 
not  likely  to  become  infected  separately,  and  if  they  do, 
they  will  rupture  into  one  of  the  larger  pockets. 

Upon  the  dorsum  two  areas  will  be  found,  in  each  of 
which  pus  can  accumulate  to  the  exclusion  of  the  other. 
To  these  are  given  the  names  dorsal  subcutaneous  space 
and  dorsal  subaponeurotic  space.  We  shall  find  that 
while  the  pus  may  lie  at  various  levels  in  the  subcutaneous 
tissue,  from  an  anatomical  standpoint,  yet  for  surgical 


A   STUDY  OF  SERIAL  CROSS-SECTIONS 


85 


purposes  any  subdivision  of  this  vspace  is  unnecessary  and 
confusing. 

Section  I.  Beginning  with  a  cross-section  which  hes 
just  distal  to  the  web  of  the  fingers,  we  note  the  following 
facts:  The  index  finger  is  slightly  different  from  the 
middle  and  ring  fingers  in  that  the  space  which  is  most 
superficial,  and  which  we  will  call  "the  subcutaneous 
space,"  does  not  extend  around  the  entire  finger,  as  do 
the  others,  but  at  the  radial  side  the  perifascial  space 
tissue  is  so  dense  as  to  obliterate  it.  It  will  be  noted 
that  this  space  is  deep,  and  that  between  it  and  the  skin 
is  to  be  found  considerable  tissue  which  is  rather  dense 


Extensor  communis  tendon 
Dorsal  subaponew  oHc  space  ^ 


Proximal  phalanx 


Subcutaneous  space 

Synovial  sheath 


Flexor  tendon 


Digital  vessels  and  nerves 
Fig.  25. — Cross-section  No.  I.     TFie  tendon  sheaths  are  shown  in  red-. 

and  does  not  lend  itself  readily  to  the  spread  of  pus,  which 
in  this  area  is  more  likely  to  come  to  the  surface  or  infect 
the  space  above  mentioned,  where  it  will  have  little 
difficulty  in  spreading  proximally  or  distally  (Fig.  25). 

The  little  finger  corresponds  with  the  index  finger  in 
that  the  space  is  obliterated  upon  its  ulnar  side.  Between 
the  tendon^  and  the  bone  in  each  of  the  four  fingers  there 
is  a  second  space,  and  to  this  we  will  give  the  name  of 
''dorsal  subaponeurotic  space  of  the  finger,"  for  upon 
each  side  of  the  tendon  a  dense  sheet  of  tissue  is  given  off, 
which  unites  firmly  with  the  periosteum  at  each  side. 
Upon  the  flexor  surface  are  found  the  flexor  tendons 
in  their  synovial  sheaths,  which  sheaths  are  so  closely 


86 


METHODS  OF  STUDY  IX  GEXERAL 


united  to  the  periosteum  that  no  definite  free  spaces  can 
be  found. 

The  importance  of  the  close  attachment  of  the  tendon 
sheath  to  the  bone  will  be  brought  out  when  discussing 
tendon-sheath  infection  in  relation  to  the  frequency  of 
osteomyelitis  secondary  to  this  trouble. 

The  spaces  above  mentioned  all  pass  through  this 
serial  section  into  the  next,  the  second  cross-cut  being 
made  through  the  epiphysis  of  the  proximal  phalanx. 

Section  II.  In  this  section  the  salient  points  may  be 
pointed  out  briefly,  so  that  we  can  retain  a  composite 
picture  with  that  which  has  just  been  described  (Fig.  26). 


Dorsal  subcutaneous  space 
Extensor  communis  tendon 
Digital  vessels  and  nerves 


Dorsal  subaponeurotic  space 
.Inferossei  muscles 


Epiphysis  proximal 
phalanx 


Lumbrical  mw-cle ' 


Lumbrical  muscle 
,-  '■'        Flexor  tendon 
Digital  vessels  and  nerves 


Flexor  tendon 

Lumbrical  muscle 


'  Synovial  sheath 

Digital  vessels  and  nerves 


Fig.  26. — Cross-section  No.  II.     Through  epiphysis  of  proximal  phalanx. 

The  tendon  sheaths  are  shown  in  red. 


The  subcutaneous  space  is  continuous  with  that  in 
Section  I. 

The  subaponeurotic  space  is  also  continuous  and  the 
interossei  muscles  begin  to  appear — one  part  attached 
to  the  periosteum  and  one  part  to  the  dorsal  aponeurotic 
sheet.  ]More  important  still,  we  see  the  beginning  of  the 
lumbrical  muscles,  and  note  particularly  the  relation  of 
this  muscle  to  the  subcutaneous  space,  especially  in  the 
third  finger. 


A  STUDY  OF  SERIAL  CROSS-SECTIONS 


87 


The  flexor  tendons  are  still  covered  by  their  synovial 
sheaths. 

Ask  yourself  where  pus  would  go  to  if  it  followed  down 
along  the  lumbrical  muscle  from  the  palm.  As  we  follow 
these  spaces  into  the  next  section,  we  will  see  that  the 
subcutaneous  spaces  upon  the  abutting  sides  of  the 
fingers  merge  into  each  other;  that  is  to  say,  for  example, 
the  subcutaneous  spaces  of  the  ulnar  side  of  the  index 
finger  and  the  radial  side  of  the  middle  finger  join  at  the 
web,  being  in  close  relation  to  the  lumbrical  muscles; 
slightly  proximal  to  this,  as  will  be  seen  in  the  next  serial 


Articular  bwface 
Extensor  communis  ti  ndon ,      / 


InU  robbci  muscles  i^ 


Dorsal  subcutaneous  space 

,  Metacarpal  bone 


jumbrical  muscle'^  I  I 

Digital  vessels  and  nerves  i 

Synovial  sheath 


\  Se'^amoid  bone 


I  \  Dense  fibrous  tissue 

'  ^Digital  vessels  and  nerves 

Flexor  tendon 


Fig.  27. — Cross-section  No.  III.     Proximal  to  metacarpo-phalangeal  joint. 
The  tendon  sheaths  are  shown  in  red. 


section,  the  space  is  obliterated  between  the  fingers,  and 
only  a  small  part  remains  upon  the  dorsum  of  each  finger. 
It  is  in  connection  with  the  space  about  the  lumbrical 
muscle  in  the  palm,  however,  so  that  pus  may  spread  from 
the  palm  downward-  into  this  space  and  thus  point  on  the 
dorsum.  (For  schematic  drawing  showing  this,  see  Fig. 
151.)  The  dorsal  subaponeurotic  space  is  obliterated  in 
this  section,  i.  e.,  at  the  joint. 

Section  III.  The  distal  surface  of  the  third  serial 
section  is  seen  upon  a  cut  0.5  cm.  proximal  to  the  joint 
(Fig.  27).     Note  here: 


88 


METHODS  OF  STUDY  fX  GEXRRAL 


The  absence  of  the  subaponeurotic  space,  except  for 
small  diverticula  lying  between  the  tw^  parts  of  the 
interossei  muscle. 

The  absence  of  the  subcutaneous  s]  Ixlween  the 

fingers.     It  is  continued,  however,  in  t'  I  subcuta- 

neous space  and  the  space  about  the  -  il  muscle^ 

That  the  luml)rical  muscle  lies  in  a  sheat:.  'I  its  own, 
as  it  were.  This  communicates  with  the  subcutaneous 
space  of  the  fingers,  and  should  be  followed  carefully  into 
the  palm. 


Dorsal  subaponeurotic  space 
Veins  ^ 
Extensor  communis  tendon 


Dense  fibrous  tissue 


Dorsal  subcutaneous  space 

Interossei  muscles 

Metacarpal  bone 


Radialis  indicis 


"  -,  Digital  vessel 
and  nerve 


Flexor  tendon  ; 

Digital  vessel  and  nerve  • 

Middle  flexion  crease 

Middle  palmar  space' 


•  Thenar  space 

Adductor  transversus  pollicis 
y 

Synovial  sheath 

Fig.  28. — Cross-section  No.  IV.   Two  cm.  proximal  to  joint.   The  tendon  sheaths 
are  shown  in  red.     Note  the  beginning  of  the  middle  palmar  space. 


The  dense  layer  of  tissue  that  crosses  the  whole  section 
lying  around  and  over  the  tendon  sheaths  and  under  the 
lumbrical  muscle. 

That  the  flexor  tendons  are  surrounded  by  their  sheaths. 

The  spaces  are  all  obliterated  in  passing  either  through 
this  section  or  the  previous  one,  except  the  synovial  space 
about  the  flexor  tendons,  that  about  the  lumbrical  muscles, 
and  the  slight  channel  on  the  dorsum,  above  noted,  passing 
between  the  subcutaneous  tissue  of  the  finger  and  the 
hand. 


A   STUDY  OF  SERIAL  CROSS  SECT  FOX  S 


89 


The  surgical  application  of  this  will  be  brought  out 
later. 

Section  IV.  The  fourth  cross-section  lies  two  centi- 
meters above  the  joint  (Fig.  28). 

The  dorsal  subaponeurotic  spaces,  which  were  oblit- 
erated at  the  joint,  are  beginning  again  between  each 
tendon  and  the  corresponding  bone. 

The  dorsal  subcutaneous  spaces  approximate  each 
other. 


Dorsal  subcutaneous  space , 
Extensor  communis  tendon 
Dorsnl  subaponeu- 
rotic space  \ 


Interosseous  vessels  . 
and  nerves   "j 


Dorsal  interosseous  membrane 
.  Vein 

Interosseous  muscle 
^Metacarpal  bone 


Hypothenar  muscles 

with  intermuscular 

spaces 


Space  between  adductor 
^ ,     transversus  and  first 
'^       dorsal  interosseous 

-Radialis  indicis 


Middle  palmar  space 

Ulnar  bursa ' 
Ulnar  vessel  and  nerve 

Flexor  tendon 


Lximbrical  muscle 
Adductor  transversus  polhcis' 


Flexor  longus  pollicis 
■  Thenar  space 
Palmar  fascia 


\ 


Fig.  29. — Cross-section  No;  V.     Three  and  a  half  cm.  proximal  to  joint.     The 
tendon  sheaths  are  shown  in  red  (ulnar  bursa  and  radial  bursa). 

The  palmar  tissue  is  still  dense,  with  no  free  pass-ges 
except  tlvose  about  the  lumbrical  muscles  and  those 
along  the  sheaths  of  the  tendons  which  are  still  present, 
and  begin  to  be  obliterated  as  the}^  pass  through  this 
serial  section. 

As  yet  no  space  has  appeared  into  which  pus  would 
extend  if  it  were  to  pass  proximally  along  these  synovial 
sheaths.     We   note,    however,    that   a   small    space   has 


90  METHODS  OF  STUDY  IN  GENERAL 

appeared  just  above  the  small  piece  of  adductor  trans- 
versus  muscle,  which  will  become  the  thenar  space. 

Now  let  us  imagine  ourselves  following  through  this 
serial  section  into  the  next.  The  free,  open  spaces  of  the 
hand  appear  suddenly,  the  synovial  sheaths  of  the  ten- 
dons become  obliterated  after  entering  them,  the  lumbrical 
muscles  join  the  tendons,  and  the  adductor  transversus, 
which  is  the  keynote  to  the  thenar  space  begins  to  assume 
its  characteristic  relations. 

Section  V.  If  we  cut  across  about  three  centimeters 
above  the^  joint,  we  find  the  following,  which  is  well, 
represented  in  Fig.  29. 

The  Middle  Palmar  Space. 

There  is  a  large,  free  space  with  few  fibrous  septa 
extending  from  the  middle  metacarpal  bone  to  the  radial 
side  of  the  metacarpal  bone  of  the  little  finger.  It  is 
bounded  dorsally  by  a  thin  fibrous  sheet  which  overlies 
the  anterior  interosseous  membrane  and  the  interossei 
muscles;  upon  its  palmar  side  is  a  second  thin  sheet 
separating  it  from  the  tendons  and  the  lumbrical  muscles 
of  the  little  and  ring  fingers.  The  space  is  limited  upon 
its  ulnar  side  by  dense,  fibrous  tissue,  and  upon  its  radial 
side  by  a  dense,  fibrous  sheet  which  lies  over  the  adductor 
transversus.  This  space  is  probably  the  most  important 
in  the  hand,  and  to  it  is  given  the  name  of  "Middle 
Palmar  Space." 

If  we  were  to  note  the  layers  of  tissue  through  the 
middle  of  the  hand,  going  from  the  palm  to  the  dorsum, 
they  would  be  as  follows: 

1.  Epidermis. 

2.  Dermis. 

3.  Firmly  meshed  subdermal  connective  tissue. 

4.  Palmar  aponeurosis. 

5.  Loose  mesh  of  connective  tissue,  in  which  lie  (a) 
vessels;  (b)  tendons  with  lumbrical  muscles,  or  ending 
of  the  synovial  sheaths. 


THE  THENAR  SPACE  91 

6.  Anterior  middle  palmar  sheet. 

7.  Middle  Palmar  Space. 

8.  Posterior  middle  palmar  sheet. 

9.  X'^essels. 

10.  Palmar  interosseous  membrane, extending  from  bone 
to  bone. 

11.  Interossei  muscles. 

12.  Posterior  interosseous  membrane. 

13.  Dorsal  subaponeurotic  space  filled  with  thin-meshed 
connective  tissue  and  vessels. 

14.  Dorsal  aponeurosis  and  tendons. 

15.  Dorsal  subcutaneous  space,  with  loose  connective 
tissue. 

16.  Dermis. 

17.  Epidermis. 

The  Thenar  Space. 

Upon  the  radial  side  we  note  the  large  mass  of  the 
adductor  transversus,  and  upon  its  palmar  side  is  shown 
a  large  space  extending  from  the  metacarpal  bone  of  the 
middle  finger  over  the  muscle  to  the  radial  side  of  the 
hand,  stopping,  however,  at  the  middle  of  the  radial  side, 
at  about  the  level  of  the  palmar  surface  of  the  bones;  or, 
in  other  words,  being  L-shaped  in  cross-section.  It  will 
be  seen  later  that  this  limitation  is  of  importance,  since 
it  prevents  injection  masses  from  passing  freely  to  the 
dorsum  of  the  hand,  or  vice^versa^  This  space  is  known 
as  the  "Thenar  Space."  Upon  its  palmar  side  there  is  a 
strong  layer  of  tissue,  blending  into  the  dense  tissue  of  the 
palm,  and-between  this  dense  palmar  tissue  and  the  space 
lie  the  tendon  and  lumbrical  muscle  of  the  index  finger. 
Over  the  adductor  muscle  is  a  thin  layer  of  tissue  or 
perimuscular  sheath. 

The  middle  palmar  and  thenar  spaces  are  the  two 
most  important  spaces  in  the  hand,  and  it  is  well  to 
note  their  relations  to  each  other  and  to  adjacent  struct- 
ures.    They  will   be  taken    up   later,   and    a   composite 


92 


METHODS  OF  STUDY  IN  GENERAL 


picture  made  from  the  fraj^mentar^-  description  noted 
here  and  in  the  following  serial  sections. 

Upon  the  dorsum  the  dorsal  subcutaneous  and  sub- 
apcmeurotic  spaces  are  well  shown. 

The  synovial  sheaths  have  entirel>^  disap])eared  except 
for  a  small  prolongation  along  the  little  finger  tendon 
and  that  al^out  the  flexor  longus  pollicis.  The  tendon 
sheaths  of  the  three  tendons  were  obliterated  while  passing 
through  this  section.     The  ulnar  bursa,  however,  is  seen 


Hypothenar  niuscU  s    r 
with  intermuscular  L 
spaa  6  i 


Palmar  interosseous  membrane 

Dorsal  subcutaneous  space . 

Extensor  commu 

Dorsal  suba 

roti 

Deep  palmar  a 


Ulnar  bur^a 


Interossei  muscles 

Metacarpal  bone 
I  Space  between  adductor 

transversus  and  first 
('(I! sal  interosseous 

Dorsalis  indicis 

artery 


Metacarpal  bone 
of  the  thumb 


Thenar  space 


^  ^  Thenar  7)iuscles 
\  f  lexor  longus  pollicis 
\        '' Adductor  transversus  pollicis 
\Palmar  fascia 
Lumbrical  muscle 


Ulnar  vein  and  nerve  ;  I 

Middle  palmar  space 

Median  artery  and  ri^w 
,      Tendon  middle  finger 

Fig.  30. — Cross-section  No.  VI.     Through  distal  part  of  thenar  area. 
The  ulnar  and  radial  bursae  are  shown  in  red. 


to  lie  in  juxtaposition  to  the  middle  palmar  space  as  do 
the  tendon  sheaths  of  the  middle  and  ring  finger  distal 
to  this  section.  The  tendon  sheath  of  the  index  finger  is  in 
close  connexion  with  the  thenar  space. 

Section  VI  (Fig.  30).  This  serial  section  is  taken 
through  the  distal  part  of  the  thenar  eminence,  and  thus 
shows  the  metacarpal  bone  of  the  thumb  in  cross-section. 
Here  we  note  the  great  relative  size  of  the  thenar  space, 
and  yet  it  is  all  upon  the  radial  side  of  the  middle  meta- 
carpal.    The    lumbrical    muscle    and    index    tendon   are 


THE  THENAR  SPACE  '  93 

separated  from  it  by  a  much  thinner  septum  than  in  the 
previous  section.  The  tendon  of  the  flexor  longus  pollicis 
appears  here  surrounded  by  its  synovial  sheath. 

The  middle  palmar  space  is  much  smaller  and  a^ill 
lies  under  the  group  of  tendons  of  the  middle,  ring,  and 
little  fingers.  Upon  the  ulnar  side  of  this  group  we  see 
the  ulnar  synovial  bursa  in  juxtaposition  to  the  space, 
yet  the  septum  between  them  must  be  strong  since  the 
injection  masses  in  this  bursa,  noted  later,  have  a  greater 
tendency  to  rupture  into  the  forearm  than  into  this  space. 

Upon  the  dorsum  we  still  find  our  subaponeurotic  and 
subcutaneous  spaces,  while  over  the  thenar  area  the  sub- 
cutaneous tissue  is  also  lax,  and  either  of  the  two  former 
spaces  can  be  made  to  communicate  with  it^ 

The  deep  palmar  arch  appears  in  this  section,  and  its 
relation  to  the  middle  palmar  space  and  the  synovial 
sheath  should  be  noted^  We  see  that  there  is  not  much 
danger  of  injuring  it  if  care  is  taken  in  operating. 

In  the  cases  e]|p,mined  the  flexor  longus  pollicis  with 
its  tendon  sheath  is  separated  from  the  thenar  space  by  a 
considerable  amount  of  tissue,  and  while  rupture  from  it 
into  the  space  is  possible  (particularly  in  those  cases 
accompanied  by  inflammatory  djfetruction) ,  yet  it  would 
be  more  likely  to  rupture  at  the  upper  end  of  the  synovial 
sac  into  the  cellular  ti^gue'of  the  forearm.  Experimental 
evidence  to  suppo^^^this  wilt^be  brought  forward  later 

Section  \^I fivJ^HQMir  ^ y^  seventh  section,  taken 

cance.  They  lie  close  togetneHUHB^e  g^Qup^  of 
tendons,  the  middle  palmar  space  bcnift'ii^jS^ superficial. 
They  are  still  separated  by  a  thin  sheet,  In  >  in  those 

specimens  examined. 

One  or  two   indefinite  spaces  are  present 
thenar  region.     They  are  of  little  importance,' 


94 


METHODS  OF  STUDY  IN  GENERAL 


except  to  note  that  they  are  present  between  the  groups 
of  muscles,  and  localized  infection  can  occur  in  them  under 
exceptional  circumstances. 

The  dorsal  spaces  remain  the  same,  except  that  the 
subaponeurotic  is  more  constricted. 

The  tendon  sheaths  are  seen  in  four  places- — the  ulnar 
bursa,  the  sheath  about  the  flexor  longus  pollicis,  and  the 
two  intermediate  sheaths  about  the  superficial  tendons 
in  juxtaposition  to  the  ulnar  bursa.  These  w\\\  be  dis- 
cussed later  (see  pp.  io6  and  107). 


Extensor  communis  tendon 
Dorsal  subcutaneous  space    \ 
Dorsal  subaponeurotic  space , 
Ulnar  bursa 


Metacarpal 


Middle  palmar  space 
Thenar  space 


Metacarpal  hone 

Radial  artery 


Hypothenar  muscles 
with  intermuscular 
spaces 


Space  between  adducto? 
transversus  and  first 
dorsal  interosseous 


Ulnar  vessels  and  nerve 

Synovial  sheath 

Flexor  tendon 


I  .  Thtnar  tnuscles 

'  Flexor  longxis  pollicis 

Median  nerve  and  vessels 


Fig.  31. — Cross-section  No.  VII.     The  ulnar  and  radial  bursae  and  the  inter- 
mediate tendon  sheaths  are  outlined  in  red. 


The  Hypothenar  Space. 

Nothing  as  3^et  has  been  said  of  the  hypothenar  area, 
since  it  was  desirable  to  avoid  confusion.  However,  a 
glance  at  this  section,  and  at  those  which  have  preceded, 
shows  very  clearly  that  while  it  is  possible  for  pus  to 
accumulate  in  the  intermuscular  septa  of  this  space,  yet 
it  would  be  absolutely  localized  here,  and  would  spread 
to  the  surface.     It  would  not  enter  either  the  middle 


THE  HYPOTHENAR  SPACE 


95 


palmar  space  or  the  ulnar  synovial  bursa.  Such  infections 
would  be  of  little  surgical  interest,  owing-  to  their  localized 
nature. 

Section  VIII  (Fig.  32).  In  the  eighth  section,  taken 
at  the  wrist,  the  middle  palmar  and  thenar  spaces  can 
still  be  found,  but  they  are  so  small  as  to  be  of  little 
practical  importance,  since  any  inflammation  in  them 
would  probably  be  followed  by  closure.  Their  behavior 
under  forcible  injection  will  be  noted  later. 


Extensor  communis 
Synovial  sheath 


Extensor  minimi  digiti 


Extensor  carpi  ulnans 


Extensor  secundi  internodii 
polhci'b 

^Middle  palmar  space 

Extensor  carpi  radialis 
brevior 

'-'Extensor  carpi  radialis 
longior 
Radial  vessels  and 


_Extensor  primi 
internodii  pollids 


Hypothenar  muscles 
with  intermuscular''' 
spaces 


Ulnar  vessels  and  nerve 


Thenar  muscles 


Ulnar  bursa 

Pabnaris  longus' 


Flexor  longus  pollids 
Synovial  sheath 

Median  nerve  and  vessels- 


Fig.  32.— Cross-section  No.  VIII.  The  ulnar  bursa,  radial  bursa,  and  inter- 
mediate sheaths  are  shown  in  red. 

While  it  might  be  possible  by  forcible  injection  to 
produce  a  dorsal  subaponeurotic  space,  yet  it  should  not 
be  described  as  being  present. 

The  dorsal  subcutaneous  space  can  be  demonstrated, 
but  it  is  more  difficult  to  do  so  here  than  in  the  previous 
sections,  since  more  of  the  fibers  tend  to  intermingle  from 
layer  to  layer. 


96  METHODS  OF  STUDY  IN  GENERAL 

The  synovial  sheaths  about  the  dorsal  tendons  also 
appear  in  this  section. 

Discussion  of  the  Relations  of  the  Middle  Palmar  and  Thenah  Spaces. 

The  inter-relation  of  the  middle  palmar  and  thenar 
spaces  is  of  very  great  interest  to  the  surgeon,  and  to 
understand  it  the  roof  and  floor  of  the  two  spaces  must 
be  discussed  together.  They  are  separated  from  each 
other  at  the  middle  metacarpal  bone  by  firm  septa  so 
that  neither  one  communicates  with  the  other,  nor  does 
either  oxerlap  to  the  other  side  of  this  bone.  The  tendons 
of  the  third  and  fourth  fingers,  with  their  lumbrical 
muscles,  lie  just  above  the  middle  palmar  space,  separated 
from  it  by  only  a  thin,  indefinite  membrane,  while  upon 
the  palmar  side  of  this  group  are  a  few  indefinite  spaces; 
but  pus  must  pass  around  the  tendons  to  their  dorsal 
surface  and  rupture  into  the  middle  palmar  space,  since 
in  every  other  direction  firm  tissue  is  found.  Such  a 
course  might  be  followed  in  an  infection  passing  upward 
along  the  lumbrical  muscles.  If  it  follows  along  the 
synovial  sheath  of  the  ring  finger,  and  finally  ruptures 
from  the  proximal  blind  end,  it  will  pass  ultimately  into 
this  space.  The  same  holds  true  for  the  tendon  sheath  of 
the  little  finger  in  those  cases  in  which  it  is  separated  from 
the  ulnar  bursa.  To  the  ulnar  side  of  the  tendon  of  the 
little  finger  is  seen  the  small  synovial  space  representing 
the  continuation  of  the  synovial  sheath  of  the  little  finger 
into  the  synovial  sheath  of  the  tendons  above,  known  as 
the  ulnar  bursa. 

It  will  be  seen  that  the  lumbrical  muscle  and  tendon 
of  the  index  finger  occupy  the  same  relative  position 
to  the  thenar  space  that  the  third  and  fourth  do  to  the 
middle  palmar  space,  with  this  exception,  that  in  those 
hands  which  have  been  examined  the  sheet  of  tissue 
separating  it  from  the  thenar  space  is  somewhat  firmer; 
still,  it  is  not  so  dense  as  that  upon  the  other  three  sides, 


THE  MIDDLE  PALMAR  AND  THENAR  SPACES        97 

and  here  also,  then,  it  miKst  communicate  with  the  space 
below  it. 

The  lumbrical  muscle  and  tendon  of  the  middle  finder 
in  Section  VI  occupy  an  intermediary  place  between  the 
two  spaces,  but  in  the  previous  section  they  will  be  seen 
to  lie  over  the  middle  palmar  space  at  which  site  the 
enveloping  fascia  is  much  thinner,  so  that  we  would  have 
reasons  to  believe,  from  an  anatomical  standpoint,  that 
pus  spreading  along  this  tendon  would  communicate 
more  easily  with  the  middle  palmar  space,  and  experi- 
mental injections  of  the  synovial  sheath  substantiate  this 
reasoning. 

We  have  now  discussed  all  of  the  relations  of  these 
spaces  except  the  floor,  or  dorsal  surface,  and  the  proximal 
prolongation.  The  latter  we  will  speak  of  in  the  chapter 
dealing  with  anatomy  of  the  forearm.  Concerning  the 
floor,  however,  it  is  well  to  mention  several  things.  Owing 
to  the  closed  nature  of  these  pockets,  it  is  customary  for 
clinicians  to  draw  attention  to  the  frequency  of  rupture 
from  them,  through  between  the  bones,  to  the  dorsal 
surface. 

In  the  middle  palmar  space  the  floor  is  composed  of  a 
very  thin  fascial  layer,  through  which  pus  could  rupture 
easily,  were  it  not  for  the  support  given  it  by  the  interossei 
muscles  and  the  interosseous  membrane,  upon  which  it 
lies.  Should  inflammatory  destruction  of  this  sheet 
arise,  however,  or  rupture  ensue,  the  interossei  muscles 
would  still  offer  a  slight  resistance,  for  there  is  no  distinct 
channel  leading  to  the  dorsum,  although  the  intermuscular 
septa  do  tend  in  that  direction.  Having  come  through 
these,  however,  the  pus  would  then  meet  the  septum 
passing  from  one  bone  to  the  other  upon  the  dorsal  surface 
of  the  interossei  muscles.  If  the  pus  meets  and  overcomes 
the  various  obstructions,  which  it  might  do  in  chronic  and 
exceptional  cases,  it  would  then  lie  beneath  the  tendons 
upon  the  dorsal  surface,  or  in  the  dorsal  subaponeurotic 
space. 


9S  METHODS  OF  STUDY  IX  GENERAL 

Now  let  us  go  back  to  the  thenar  space  and  its  floor, 
or  dorsal  wall.  This  is  slightly  more  complex,  in  that 
the  muscular  masses  making  u])  the  floor  confuse  us. 
For  the  most  part  it  is  made  up  of  the  adductor  transverse 
and  the  adductor  obliquus,  and  in  those  cases  where  there 
is  little  tension  upon  the  contents  it  would  be  limited 
dorsally  by  them  and  the  thin  sheet  of  fascia  over  the 
muscles.  Upon  the  other  hand,  if  the  tension  were 
increased,  it  would  be  very  easy  for  the  contents  of  the 
cavity  to  pass  between  these  muscles  and  come  to  lie 
upon  the  dorsal  surface  of  the  adductor  transversus. 
That  is  to  say,  it  would  come  against  the  first  dorsal 
interosseous  upon  the  dorsum  of  the  thenar  region  about 
on  a  level  with  the  metacarpo-phalangeal  joint  of  the 
thumb,  and  thus,  if  there  were  any  inflammatory  action 
present,  spread  to  the  cutaneous  tissue  at  the  web;  or, 
if  the  dorsal  interosseous  muscles  were  unimportant,  in 
the  dorsal  subcutaneous  tissue  of  the  thenar  region. 
Experimental  evidence  will  be  adduced  later  to  prove  this 
can  occur. 

Resume. 

We  note  that  we  have  six  important  fascial  spaces 
with  their  tributaries  in  which  pus  can  accumulate. 

1.  The  dorsal  subcutaneous,  which  is  an  extensive 
area  of  loose  tissue,  without  definite  boundaries,  allowing 
pus  to  spread  over  the  entire  dorsum  of  the  hand. 

2.  The  dorsal  subaponeurotic,  limited  upon  its  sub- 
cutaneous side  by  the  dense  tendinous  aponeurosis  of  the 
extensor  tendons,  upon  the  deep  side  by  the  metacarpal 
bones,  having  the  shape  of  a  truncated  cone,  with  the 
smaller  end  at  the  wrist  and  the  broader  at  the  knuckle. 
Laterally  the  aponeurotic  sheet  shades  off  into  the 
subcutaneous  tissue. 

3.  The  hypothenar  area,  a  distinctly  localized  space, 
not  communicating  with  the  other  spaces,  or  in  relation 
to  any  tendon  sheath. 


METHODS  OF  STUDY  /X  GENERAL  09 

4.  The  thtMiar  space,  occupying,  approximately,  the 
area  of  the  thenar  eminence.  Superficially  its  internal 
boundary  is  indicated  by  the  adduction  crease  of  the 
thumb.  It  lies  entirely  upon  the  radial  side  of  the  middle 
metacarpal.  It  should  be  remembered  that  this  space  lies 
deep  in  the  palm,  just  above  the  adductor  transversus. 

5.  The  middle  palmar  space,  with  its  three  diverticula 
below  along  the  lumbrical  muscles,  limited  by  the  middle 
metacarpal  bone  upon  the  radial  side,  overlapped  by  the 
ulnar  bursa  upon  the  ulnar  side,  and  separated  from  the 
thenar  space  by  a  partition  which  is  very  firm  everywhere 
except  at  the  proximal  end,  where  it  is  rather  thin.  A 
small  isthmus  can  be  found  leading  from  the  proximal  end 
of  the  space  under  the  tendons  and  ulnar  bursa  at  the 
wrist  into  the  forearm. 

6.  The  web  space,  an  area  of  loose  connective  tissue 
between  the  bases  of  the  fingers  with  prolongations  distally 
into  the  subcutaneous  tissue  at  the  sides  of  the  fingers, 
and  proximally  into  the  subcutaneous  tissue  of  the  dorsum 
on  the  dorsal  surface  and  into  the  connective-tissue  spaces 
around  the  lumbrical  muscle  on  the  palmar  surface.  The 
corroboration  of  our  statement  as  to  the  outlines  of  these 
spaces  will  be  brought  out  in  the  chapter  upon  experi- 
mental injections  (Chapter  IX). 


J 


CHAPTER   VIII. 

THE  TENDON  SHEATHS:  A  DISCUSSION  OF 
THEIR  ANATOMICAL  DISTRIBUTION  AND 
RELATIONS,  WITH  SURGICAL  DEDUCTIONS. 

From  a  consideration  of  the  cross-sections  we  have 
described  in  the  previous  chapters  it  is  possible  to  give  a 
composite  picture  of  the  various  tendon  sheaths  from  an 
anatomical  and  surgical  standpoint.  In  the  following 
description  the  well-known  anatomical  points  which  have 
no  bearing  on  the  subject  in  hand  will  not  be  dealt  with. 
It  is  my  intention  to  emphasize  those  facts  which  will  aid 
us  in  understanding  the  course  an  infection  will  pursue, 
and  will  point  to  the  proper  course  of  treatment.  There- 
fore, before  reading  this  the  student  should  have  a  clear 
conception  of  the  anatomy  of  the  six  fascial  spaces  des- 
cribed in  the  previous  chapter. 

The  particular  relation  of  the  sheaths  to  the  six  fascial 
spaces  will  be  emphasized  in  the  chapter  dealing  with 
experimental  injections  (Chapter  IX).  These  injection 
results  will  also  serve  to  corroborate  the  anatomical 
statements  made  here. 

SHEATHS  UPON  THE  FLEXOR  SURFACE. 

From  a  surgical  standpoint,  the  sheaths  upon  the 
flexor  surface  are  the  most  important.  The  anatomy 
of  these  may  be  discussed  under  four  heads:  (i)  The 
tendon  sheaths  for  the  index,  middle,  and  ring  fingers; 
(2)  the  tendon  sheath  for  the  thumb  with  its  prolongation 
in  the  hand  (radial  bursa);  (3)  the  tendon  sheath  of  the 
little  finger  and  its  prolongation  in  the  palm  (ulnar  bursa) ; 

(4)  the  communications  between  these  various  sheaths. 

( 100 ) 


SHEATHS  OF  INDEX,  MIDDLE  AND  RING  FINGERS     101 

The  Sheaths  of  the  Index,  Middle  and  Ring  Fingers. 

These  begin  just  distal  to  the  distal  interphalangeal 
joint  and  extend  into  the  palm,  approximately  a  thumb's 
breadth  proximal  to  the  web;  or  the  point  of  extension  can 
be  designated  by  drawing  a  line  between  the  end  of  the 
proximal  palmar  crease  at  the  base  of  the  index  finger 
and  the  end  of  the  distal  palmar  crease  at  the  base  of  the 
littl_e.  finger,  This  line  represents  the  approximate  exten- 
sion of  these  sheaths  into  the  palm.  It  will  be  seen  by 
noting  Fig.  28  that  at  the  distal  portion  of  the  palm  there 
is  a  sheet  of  dense  tissue  enclosing  the  tendon  sheaths  and 
lumbrical  muscles.  The  sheaths  extend  one-fourth  inch 
proximal  to  this  into  the  loose  palmar  tissue.  This  fact 
is  of  considerable  importance  from  a  surgical  standpoint 
(see  pp.  117  and  164). 

While  passing  through  the  dense  tissue  mentioned 
above,  these  sheaths  have  on  either  side  the  space  called 
the  lumbrical  canal,  through  which  pass  the  lumbrical 
muscles  and  digital  branches  of  the  arteries  and  nerves 
(Fig.  2y).  This  is  also  of  surgical  importance  (see  pp. 
178  and  208). 

As  we  pass  distally,  we  find  considerable  tissue  between 
the  metacarpo- phalangeal  joint  and  the  sheath  proper, 
while  more  distally,  as  we  come  to  the  base  of  the  proximal 
phalanx,  we  note  that  the  sheath  approaches  the  bone 
and  is  in  close  relation  with  the  loose  connective  tissue 
going  entirely  around  the  bone.  The  surgical  importance 
of  this  will  be  brought  out  later. 

At  thfe  proximal  interphalangeal  joint  (Fig.  144)  we 
find  considerable  tissue  between  the  sheath  and  the 
joint,  while  over  the  base  of  the  middle  phalanx,  i.  e., 
at  the  epiphyseal  line  (Fig.  33)  there  is  little  or  no  tissue 
between  the  sheath  and  the  bone.  From  this  point 
distally  the  relation  to  the  bone  is  not  so  intimate.  At  the 
distal  end  the  relation  of  the  structures  can  be  seen  by 


102  THE  TEX  DON  SHEATHS 

studying  Fig.  2,    (For  surgical  application,  see  p.  160  and 
Chapter  XXIX.) 

These  sheaths  bear  almost  the  same  relation  to  the 
respective  fingers.  They  do  differ  slightly  in  their  rela- 
tion to  the  palm  of  the  hand  as  pointed  out  in  Chapter 
VII.  The  proximal  end  of  the  sheath  for  the  index  finger 
is  in  relation  to  the  thenar  space,  while  that  of  the  middle 
finger  is  most  often  in  relation  to  the  middle  palmar  space, 
although  at  times  it  will  allow  of  rupture  into  the  thenar 
space,  possibly  through  rupture  into  the  lumbrical  space 


Fig.  ^i. — Cross-section  through  the  epiphysis  of  the  middle  phalanx.  Notice 
the  loose  mesh  and  the  small  amount  of  connective  tissue  between  the  tendon 
and  the  bone. 

between  the  index  and  middle  finger  and  thence  into  the 
thenar  space.  However,  this  lumbrical  space  itself  most 
often  leads  into  the  middle  palmar  space.  The  tendon 
sheaths  of  the  ring  finger  and  of  the  little  finger  are  in 
relation  to  the  middle  palmar  space. 

The  ILvdial  Bursa  and  the  Tendon  Sheath  of  the  Flexor  Longus 

pollicis. 

This  is  of  great  importance  from  a  surgical  standpoint, 
owing  to  the  fact  that  in  youth  and  adult  life  the  sheath 


THE  ULNAR  BURSA   AXD  THE  LITTLE  FINGER      103 

nearly  always  communicates  with  the  enlarged  sac  of  the 
tendon  sheath  at  the  wrist  (19  in  20  cases,  Poirier).  The 
entire  sheath  has  been  given  the  name  of  radial  bursa, 
although  technically  speaking  it  should  be  applied  only 
to  the  proximal  part  at  the  wrist. 

The  sheath  begins  distally  at  the  base  of  the  distal 
phalanx  and  extends  proximally  a  thumb's  breadth 
proximal  to  the  anterior  annular  ligament.  It  lies  first 
in  close  proximity  to  the  proximal  phalanx,  but  at  the 
distal  end  of  the  metacarpal  bone  becomes  separated 
from  the  bone  b}'  the  muscles  of  the  thumb  lying  between 
the  outer  head  of  the  flexor  brevis  poUicis  and  the  adductor 
obliquus  pollicis  (Figs.  30  and  31).  At  times  (i  to  20, 
Poirier)  there  is  a  separation  of  the  sheath  into  two  parts 
about  the  middle  of  the  metacarpal  bone.  This  is 
frequentl}^  onh'  a  thin  diaphragm.  The  sheath  is  gener- 
ally well  separated  by  connective  tissue  from  the  meta- 
carpo-phalangeal  joint  and  an  infection  may  spread  from 
the  joint  to  the  sheath,  or  vice  versa,  but  either  is  uncom- 
mon. It  lies  superficial  to  the  proximal  end  of  the  thenar 
space,  in  juxtaposition  to  the  flexor  tendons  in  the  carpal 
canal  (Fig.  30)  and  passes  upward  to  terminate  about  an 
inch  above  the  annular  ligament  by  a  rounded  cul-de-sac 
extending  under  the  deep  surface  of  the  tendon,  corre- 
sponding to  the  radio-carpal  joint  and  the  lower  end  of  the 
radius,  lying  on  the  pronator  quadratus. 

The  communication  between  this  and  the  ulnar  bursa 
will  be  discussed  later.  The  motor  nerve  to  the  thenar 
rnuscle  lies  within  a  finger's  breadth  distal  to  the  annular 
ligament  and  superficial  to  the  sheath  (see  p.  107). 

The  Ulnar  Bcrsa  and  the  Sheath  of  the  Tendon  of  the  Little  Finger. 

The  tendon  sheath  of  the  flexor  tendon  of  the  little 
finger  communicates  freeh^  with  the  ulnar  bursa  in  about 
one-half  of  the  cases  according  to  Poirier,  but  statistics 
vary  somewhat  on  this  point.     When  the  separation  is 


104 


THE  TENDON  SHEATHS 


present  it  is  of  any  grade,  from  a  single  narrowing  to  a 
complete  occlusion  some  millimeters  in  length.  In  these 
cases  the  sheath  corresponds  in  length  to  those  of  the  other 


Fig. 34. — .Y-ray  picture  upon  whichare  shown  two  types  seen  in  the  flexor  tendon 
sheaths.  Note  that  in  the  hand  upon  the  left  side  there  is  a  continuation  between 
the  little  finger  and  the  thumb  and  the  ulnar  bursa  and  radial  bursa  respectively. 
Note  also  the  connecting  sheaths  between.  In  the  hand  upon  the  right  side 
the  sheaths  are  separated,  not  alone  from  their  respective  fingers,  but  from  each 
other.  The  type  noted  upon  the  left  side  of  the  picture  is  present  in  almost  all 
cases  the  author  has  seen,  and  surgery  based  upon  this  assumption  will  be  the 
wiser  course. 


fingers.  Also  the  relations  to  the  joints  and  spaces  are 
the  same  except  that  there  is  no  lumbrical  canal  upon  the 
ulnar  side  of  the  proximal  end.  The  sheath  extends  into 
the  middle  palmar  space,  and  the  lumbrical  canal  upon  its 


THE  ULNAR  BURSA  AND  THE  LITTLE  FINGER     105 

radial  side  communicates  with  the  same  area.  In  this 
relation  it  should  be  remembered  that  these  muscles  do  not 
lead  into  the  thenar  and  middle  palmar  spaces  directly, 
but  lie  just  superficial  to  them,  in  a  loft,  as  it  were,  from 
which  pus  easily  extends  into  the  space. 

The  ulnar  bursa  proper  (Fig.  34)  begins  at  the  proximal 
end  of  the  finger  sheath,  spreads  out  rapidly  and  becomes 
a  good-sized  sac  overlapping  the  metacarpal  of  the  ring 
finger  and  the  head  of  the  middle  metacarpal,  passes 
under  the  anterior  annular  ligament  and  extends  a  thumb's 
breadth  above  this,  lying  in  relation  to  the  lower  end  of 


UB  SS  FLP 

Fig.  35. — Showing  the  relation  of  the  tendons  and  synovial  sheaths  at  the 
wrist.  Note  in  this  drawing  the  four  pockets  in  the  ulnar  bursa  instead  of  three 
as  commonly  described ;  also  the  tendon  sheath  of  the  flexor  longus  pollicis  and 
the  accessory  synovial  sheaths  (SS).  See  text  for  description  of  the  difference 
between  the  relations  of  the  tendons  shown  in  Figs.  31  and  35. 

the  ulna  and  the  ulnar  side  of  the  carpus  and  the  radio- 
ulnar articulation,  lying  upon  the  pronator  quadratus. 
It  does  not  surround  the  tendons  as  a  whole,  but  lies  to  the 
ulnar  side  of  the  group  of  superficial  and  deep  flexors  and 
only  envelops  them  as  if  they  were  pushed  in  along  the 
outside.  It  follows,  then,  that  the  ulnar  side  of  the  sac 
is  free  while  the  radial  side  envelops  the  tendons,  forming 
three  spaces  or  arches,  as  it  were,  the  most  superficial 
between  the  aponeurosis  and  the  superficial  tendons,  the 
middle  between  the  superficial  and  deep  tendons,  and  the 
third  between  the  deep  tendons  and   the  carpal  canal 


106 


THE  TENDON  SHEATHS 


(Figs.  31,  35,  and  36).  These  all  open  upon  the  ulnar  side 
into  a  common  space.  This  arrangement,  first  drawn 
attention  to  by  Leguey,  I  believe,  is  in  general  true,  but 
the  arrangement  varies  at  different  levels  and  in  different 
individuals,  as  can  be  seen  by  examining  Fig.  35,  where 

there  are  four  pockets,  and 
none  of  them  very  deep. 
Moreover,  the  tendons  upon 
the  radial  side  frequently 
have  sheaths  separate  from 
the  ulnar  bursa,  as  will  be 
mentioned  under  our  fourth 
caption  "The  Intercommun- 
ication of  the  Sheaths."  At- 
tention should  also  be  drawn 
to  the  fact  that  the  super- 
ficial palmar  arch  with  some 
of  the  unimportant  branches 
of  the  ulnar  nerve  lies  super- 
ficial to  the  sheath.  More 
important,  however,  is  the 
fact  that  the  sheath  overlies 
the  middle  palmar  space, 
making  part  of  its  roof,  as  it 
were  (Fig.  37). 

Above  the  anterior  annular 


Fig.  36. — Photographafter  Poirier, 
in  which  the  ulnar  bursa  has  been 
opened,  showing  its  extension  into 
the  little  finger  and  its  closure  about 
the  tendon  of  the  ring  finger. 


ligament    it    is    well    to    note 


that  the  tendons  of  the  pal- 
maris  longus  and  the  flexor 
carpi  radial  is  lie  above  the 
radial  bursa,  and  that  by 
drawing  the  tendon  of  the  flexor  carpi  radialis  to  the  radial 
side  one  can  come  down  directly  upon  the  flexor  longus 
pollicis  and  its  sheath.  Attention  should  likewise  be 
drawn  to  the  fact  that  the  median  nerve  lies  rather  deeply 
between  the  two  bursae. 


THE  INTERCOMMUNICATION  OF  THE  SHEATHS     107 

The  Intercommunication  of  the  Sheaths. 

Poirieri  discusses  the  communication  between  the  bursae 
as  follows: 

"The  synovial  sheaths  of  the  palm  have  no  communica- 
tion with  each  other,  and  the  authors  cite  in  proof  of  this 
the  case  of  Gosselin,  who  had  observed  it  only  once. 
However,  the  result  of  my  observation  has  been  that  this 
communication  between  the  two  important  sheaths  is  very 


Palmar  interosseous  membrane. 
Dorsal  subcutaneous  space 
Extensor  communis  tendon  ^ 
Dorsal  subaponeu- 
rotic space 
Deep  palmar  arch 


Ulnar  bursa 


Interossei  muscles 

1  Metacarpal  bone 

I  1  Space  between  adductor 

transversus  and  first 
dorsal  interosseous 

Dorsalis  indicis 
aitery 


Metacarpal  bone 
of  the  thumb 


Hypothenar  muscles 

with  intermuscular 

spaces 


Ulnar  vein  and  nerve  /  ; 

Middle  palmar  space 

Median  artery  and  nerve 

Tendon  middle  finger 


Thenar  space 


"^  Thenar  muscles 

\  Flexor  longus  pollicis 
\        ^'Adductor  transversus  pollicis 
\Palmar  fascia 
Lumbrical  muscle 


Fig.  37. — Cross-section  No.  VI*     Through  distal  part  of  "thenar  area.     The  ulnar 
and  radial  bursae  are  shown  in  red. 

frequent  in  the  adult.  It  is  found  in  about  half  of  the 
cases.  The  connection  is  made  by  a  median  synovial 
sheath  which  I  will  describe. 

"Accessory  synovial  sacs:  The  writers  call  attention 
to  the  occasional  existence  of  synovial  sheaths  in  addition 
to  the  two  large  synovial  sheaths,  which  they  call  accessor}- 
sheaths,  and  are  found  at  times  along  the  flexor  tendons 
of  the  index  finger.  They  lie  between  the  ulnar  and 
radial  bursse,  being  found  especially  along  the  deep  tendon. 


^  P.  Poirier  et  A.  Charpy,  Traite  d'anatomie  humaine,  vol.  ii,  p.  189. 


108  THE  TENDON  SHEATHS 

My  researches  show  that  these  synovial  sheaths  are  two 
in  number.  They  ought  not  to  be  called  accessory,  since 
one  of  these  is  almost  always  present.  I  have  named 
them  the  intermediary  anterior  and  posterior  palmar 
synovial  sheaths. 

"The  intermediary  posterior  palmar  sheath:  This 
should  be  described  as  a  normal  sheath,  since  one  finds 
it  about  eight  times  out  of  ten.  It  lies  between  the 
carpal  canal  and  the  flexor  profundus  of  the  index  finger, 
and  commences  above  the  wrist  at  the  edge  of  the  radius. 
It  spreads  out  at  the  level  of  the  upper  border  of  the 
semilunar  bone  and  goes  down  more  or  less  on  the  tendon 
of  the  flexor  profundus,  varying  from  3  to  8  cm.  To  see 
it,  it  is  necessary  to  cut  transversely  across  the  mass  of 
muscles  and  tendons  in  the  lower  third  of  the  forearm  and 
turn  the  distal  end  down  toward  the  fingers.  It  is  by  the 
intervention  of  this  sheath  that  the  ulnar  and  radial  bursse 
communicate  ordinarily. 

"The  anterior  intermediary  palmar  sheath:  This  is 
found  in  hardly  half  of  the  cases.  Much  smaller  than 
the  preceding,  it  is  found  placed  between  the  superficial 
and  deep  tendons  of  the  index  finger. 

"Both  of  these  appear  later  than  the  others,  and  it  is 
very  rare  to  find  them  as  completely  organized.  In 
general,  their  walls  lack  the  moist  glassiness  characteristic 
of  complete  development." 

It  is  said^  also  that  the  synovial  sheaths  of  the  ring, 
middle,  and  index  fingers  communicate  exceptionally 
with  the  ulnar  bursa,  following  their  respective  tendons, 
occurring  in  the  order  of  frequency  as  the  fingers  are 
named  above.  I  have  had  an  opportunity  to  verify  this 
observation  in  one  case  in  which  the  tendon  sheath  of  the 
ring  finger  communicated  freely  with  the  ulnar  bursa. 
Again,  attention  should  be  drawn  to  the  fact  that  the 

1  Tillaux,  Traite  d'anatomie  topographique. 


THE  INTERCOMMUNICATION  OF  THE  SHEATHS     101) 


Fig.  38. — An  x-ray  picture  of  a  cadaver  hand  in  which  the  tendon  sheaths 
have  been  injected  with  red  lead.  The  outUne  of  the  ulnar  bursa  and  radial 
bursa  with  tendon  prolongations  is  clearly  shown.  Note  the  distance  of  the 
radial  bursa  from  the  metacarpal  bone  of  the  thumb  and  the  relation  of  the 
ulnar  bursa  to  the  metacarpal  bone  of  the  middle  finger.  The  outlines  of  the 
tendon  sheaths  of  the  index,  middle  and  ring  fingers  are  not  well  shown.  The 
same  is  true  of  the  extensions  of  the  ulnar  and  radial  bursse  (see  Fig.  34). 


110  TllR  TRNDON  SllEATlIS 

intermediary  sheaths  ina>-  differ  from  liial  ty]3e  mentioned 
by  Poirier.  I  have  dissected  one  case  in  which  the  pro- 
fundus tendons  of  the  index  and  middle  fingers  had  sepa- 
rate sheaths.  Communicating  with  the  ulnar  bursa 
(Fig.  31)  at  this  level  the  anterior  intermediary  sheath 
was  absent,  but  2  cm.  higher  up  the  sheath  of  the  middle 
finger  ])rofundus  had  disappeared,  while  the  anterior  and 
posterior  intermediary  sheaths  were  present  (Fig.  35). 
The  communication,  here,  then,  would  have  taken  place 
as  follows:  I'lnar  bursa,  sheath  about  the  middle  finger 
profundus,  sheath  about  the  index  finger  profundus,  or 
posterior  intermediary  sheath,  and,  in  this  case  appar- 
ently, anterior  intermediary  sheath,  to  the  radial  bursa. 
It  can  be  seen  that  in  a  fulminating  type  of  infection,  such 
as  a  streptococcus  involvement,  the  process  would  spread 
to  the  radial  bursa,  but  in  the  more  chronic  types  this 
devious  course  offers  many  chances  for  adhesive  occlusion 
of  the  channel  (Fig.  38).  This  will  be  discussed  later 
(see  p.  207).  My  clinical  experience  would  seem  to  indi- 
cate that  the  intercommunication  of  the  radial  and  ulnar 
bursae  is  more  common  than  stated  by  Poirier,  at  least 
infection  spreads  from  the  one  to  the  other  in  a  large 
majority  of  the  cases  in  which  one  or  the  other  is  primarily 
involved. 

THE  SHEATHS  UPON  THE  DORSUM. 

The  synovial  sheaths  of  the  hand  upon  the  dorsum  are 
six  in  number.  These  begin  just  above  the  posterior 
annular  ligament  and  pass  under  and  through  it  (Figs. 
32  and  39).     They  are  found  as  follows: 

1.  Lying  upon  the  outer  side  of  the  styloid  proj:ess  of 
the  radius,  for  the  extensor  ossis  metacarpi  pollicis  and 
the  extensor  brevis  pollicis.  They  may  have  separate 
sheaths  and  are  5  to  6  cm.  in  length. 

2.  Behincl  the  styloid  process,  for  the  tendons  of  the 
extensor  carpi  radialis  longior  and  brevior.  "  These  are 


THE  SHEATHS  UPON  THE  DORSUM 


111 


5  to  6  cm.  in  length  and  comnumicate  with  the  sheath  of 
the  extensor  longus  pollicis  through  an  oval  opening  by 
way  of  the  longior  (Poirier). 


Fig.  39. — Photograph  from  Bardeleben,  showing  tendons  upon  the  back  of  the 
hand  passing  under  the  posterior  annular  ligament. 

3.  Overlapping  the  above  tendons,  and  communicating 
with  them  as  described,  we  have  the  sheath  of  the  extensor 
longus  pollicis.     This  is  6  to  7  cm.  in  length. 

4.  To  the  ulnar  side  of  this  we  find  the  large  sheath 


112  THE  TENDON  SHEATHS 

enclosing  the  tendons  of  the  extensor  communis  digi- 
torum  and  the  extensor  indicis.  It  is  5  to  6  cm.  in 
length  and  terminates  l)elow  in  three  prolongations. 
The  radial  one  encloses  the  communis  tendon  to  the 
index  finger  and  the  extensor  indicis;  the  middle,  the 
communis  tendon  to  the  middle  finger;  the  one  on  the 
ulnar  side  covers  the  tendons  to  the  third  and  fourth 
fingers. 

5.  One  opposite  the  interval  between  the  radius  and 
ulna,  for  the  extensor  minimi  digiti.  This  is  longer  than 
the  others,  being  6  to  7  cm.  in  length.  Covering  the 
upper  one-third  of  the  length  of  the  third  interosseous 
space,  it  may  l)ifurcate  below,  following  the  two  branches 
of  the  tendon. 

6.  Upon  the  back  of  the  ulna,  the  synovial  sheath  of  the 
tendon  of  the  extensor  carpi  ulnaris.  This  is  4  to  5  cm. 
in  length. 


CHAPTER   IX. 

THE  RELATION  BETWEEN  THE  SYNOVIAL 
SHEATHS  AND  THE  FASCIAL  SPACES. 

A  STUDY  BY  EXPERIMENTAL  INJECTION  OF  THE 
OUTLINES,  BOUNDARIES,  AND  DIVERTICULA  OF 
THE  FASCIAL  SPACES  AND  THE  RELATION  OF 
THESE   TO   THE   SYNOVIAL   SHEATHS. 

In  my  desire  to  corroborate  the  findings  by  dissection 
in  relation  to  the  fascial  spaces  and  tendon  sheaths 
which  have  been  detailed  in  the  two  preceding  chapters, 
a  large  number  of  hands  were  injected  after  the  manner 
described  in  Chapter  VII.  The  results  obtained  were 
most  satisfactory,  since  they  were  so  uniform  that  they 
absolutely  fixed  the  boundaries  and  relations  of  the 
spaces  and  sheaths.  Moreover,  these  experiments  gave 
results  which,  when  applied  clinically,  were  of  inestimable 
value  in  determining  the  course  the  infection  tended  to 
pursue.  Again,  they  determined  not  only  the  proper 
sites  for  opening  any  particular  focus,  but  also  indicated 
where  secondary  abscesses  would  be  located,  and  thus 
favored  early  diagnosis  and  treatment  of  such  processes. 
Furthermore,  they  demonstrated  the  relation  between 
tendon-sheath  abscesses  and  fascial-space  abscesses. 
These  studies  have  been  of  greater  aid  than  any  other 
in  placing^  the  treatment  of  infections  of  the  hand  upon 
a  scientific  basis. 

A  brief  outline  of  the  various  procedures  will  be  of  value 
in  preserving  a  general  picture.  This  will  be  followed  by  a 
discussion  of  the  individual  experiments. 

Our  first  group  of  experiments  had  for  its  object  the 
determination  of  the  relation  of  rupture  of  the  synovial 

8  (113) 


114        SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

sheaths  to  the  secondary  abscesses  in  the  fascial  spaces. 
In  other  words,  if  an  infection  began  in  a  particular 
tendon  and  ruptured  from  it,  where  would  the  secondary 
abscess  lie?  This  was  determined  by  an  extensive  series 
of  experiments  upon  each  sheath.  Clinical  evidence  has 
accumulated  in  my  hands  sufficient  to  verify  every  one  of 
the  experimental  deductions  we  have  here  made. 

The  second  problem  dealt  with  determining  the  bound- 
aries and  diverticula  of  each  of  the  definite  spaces  I  have 
described.  To  do  this,  injections  of  these  spaces  were 
made  from  every  possible  source  of  infection — the  tendon 
sheaths,  direct  implantation,  and  extension  from  neighbor- 
ing spaces.  The  results  were  uniform,  as  will  be  seen  by  a 
study  of  the  experiments. 

In  the  third  group  injections  were  made  with  great 
force  to  determine  where  pus  would  extend  when  it 
ruptured  from  these  individual  spaces. 

By  these  experiments  we  have  determined  for  the 
synovial  sheaths,  the  sites  of  extension;  and  for  each 
fascial  space,  (a)  the  source  of  involvement;  (b)  the  normal 
limitations  of  that  space;  (c)  the  areas  to  which  pus  will 
extend  from  the  space.  Here  again  clinical  evidence  will 
be  later  adduced  to  show  that  all  of  these  deductions  are 
pathologically  correct. 

For  the  sake  of  clearness  a  tabulation  of  these  experi- 
ments is  appended. 

I.  The  relation  of  rupture  of  the  tendon  sheaths  to  the 
fascial  spaces. 

From  the  tendon  sheath  of  the  middle  finger,  Experi- 
ments I  and  2. 

From  the  tendon  sheath  of  the  ring  hnger.  Experiments 
3,  4,  i8,  19,  and  20. 

From  the  tendon  sheath  of  the  little  finger.  Experi- 
ments 5,  6,  7,  and  47. 

From  the  tendon  sheath  of  the  index  finger.  Experi- 
ments 8,  9,  27,  and  35. 


OUTLINES  AND  DIVERTICULA  OF  FASCIAL' SPACES      115 

From  the  tendon  sheath  of  the  thumb,  Experiments 
10  to  17. 

II.  The  boundaries  and  diverticula  of  the  spaces. 

{a)   Middle  palmar  space. 

Injection  via  ring  finger  sheath,  Experiments  3,  4,  18 
to  20. 

Injection  via  little  finger  sheath,  Experiments  i  and  2. 

Injection  via  little  finger  sheath.  Experiments  5,  6,  7, 
and  47. 

Injection  via  palmar  fascia.  Experiments  21  to  25. 

Injection  via  lumbrical  muscle  space.  Experiments  26A 
and  26B. 

Of  these,  great  force  was  used  in  19,  20,  and  3.  From 
these  and  others,  deductions  were  made  as  to  the  location 
of  pus  extensions  from  the  middle  palmar  space. 

{b)  Thenar  space. 

Injection  via  index  finger  sheath.  Experiments  2"/  to 
35,  8  and  9. 

Injection  via  palmar  fascia,  Experiments  36,  37,  and  38. 

Of  these,  great  force  was  used  in  the  experiments  from 
27  to  35  inclusive,  and  from  the  results  deductions  were 
made  as  to  the  location  of  pus  extensions  from  the  thenar 
space. 

(c)  Dorsal  subcutaneous  space. 

Injection  between  first  and  second  metacarpals,  Experi- 
ments 39  and  40.    - 

Injection  between  second  and  third  metacarpals, 
Experiments  41  and  42. 

(d)  Dorsal  subaponeurotic  space. 
Experiments  43,  44,  and  45. 

(e)  Hypothenar  space. 

General  results  of  experiments  quoted. 

(/)  Forearm  space. 

Injection  via  flexor  longus  pollicis  sheath.  Experiments 
46,  10  to  17. 

Injection  via  ulnar  bursa  and  little  finger.  Experiments 
47  and  50. 


116         SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

Injection  via  middle  palmar  space,  Experiment  49. 
Injection  along  radial  and  ulnar  vessels,  grouped  under 
composite  experiment  51. 


THE  RELATION  OF  THE  TENDON-SHEATH  RUPTURE  TO  THE 
FASCIAL  SPACES. 

Injection  via  the  Tendon  Sheath  of  the  Middle  Finger. 

In  inserting  the  cannula  no  effort  was  made  to  reach 
any  particular  spot,  but  the  injection  mass  was  allowed 
to  rupture  through  the  weakest  spot  in  its  course.  It 
will  be  noted  that  in  each  instance  the  mass'  entered 
and  filled  the  middle  palmar  space. 


Fig.  40. — Schematic  drawing  made  from  a  dissection  of  a  hand  injected  from 
the  tendon  sheath  of  the  middle  finger.  The  mass  filled  the  middle  palmar  space 
and  extended  along  the  two  lumbricals. 

Experiment  i. — Left  hand.  Cannula  inserted  into 
tendon  sheath  of  middle  finger  at  the  middle  of  the 
proximal  phalanx,  moderate  force  used  in  injection.  The 
mass  occupied  the  middle  palmar  space  only,  going  up  to 


INJECTION   VIA    TENDON  SHEATH  OF  RTNG  FINGER     117 

about  one-half  inch  below  the  annular  ligament.  Down- 
ward it  had  returned  along  the  lumbrical  muscles  of  the 
little  and  ring  fingers  nearly  to  the  web  of  the  fingers.  It 
did  not  return  to  any  extent  along  the  lumbrical  muscles 
of  the  middle  finger.  In  every  way  this  was  a  perfect 
representation  of  what  is  probably  a  typical  collection  in 
the  middle  palmar  space.  (See  experimental  injection 
drawing,  Fig,  40,) 

Experiment  2. — Left  hand.  Same  as  No.  i  in  every 
particular.     No  mass  to  radial  side  of  middle  finger. 

Experiment  2A. — Right  hand.  Same  as  No.  i  in  every 
particular. 

Injection  via  the  Tendon  Sheath  of  the  Ring  Finger. 

The  tendon  sheath  was  opened  at  the  base  of  the 
finger  and  the  cannula  inserted  into  the  sheath  and 
pushed  through  the  proximal  blind  end  into  whatever 
space  was  at  that  site,  thus  trying  to  demonstrate  where 
an  infection  would  spread  to  if  it  extended  from  the  tendon 
sheath.  In  one  case,  which  is  not  included  in  the  report, 
the  tendon  sheath  did  not  end  blindly,  but  extended  up 
into  the  group  of  tendons  at  the  wrist.  In  every  case 
where  the  sheath  ended  normally  the  mass  filled  the 
middle  palmar  space. 

Experiment  3. — Right  hand.  Moderate  force  used. 
In  this  case  the  mass  occupied  the  middle  palmar  space 
as  it  has  been  described.  No  diverticula  w^ere  noted 
except  that  the  mass  extended  along  the  lumbrical 
muscles  of  the  ring  finger  for  about  one-half  inch.  (See 
experimental  injection  drawing.  Fig.  41.) 

Experiment  4. — Right  hand.  Moderate  force  used. 
In  this  case  the  cannula  broke  from  the  blind  end,  evi- 
dently superficial  to  the  tendon,  for  there  was  a  small 
mass  only,  lying  superficial  to  the  tendon,  about  a  quarter 
of  an  inch  wide  and  three-quarters  of  an  inch  long.  It 
had  not  involved  the  middle  palmar  space,  but  it  was  seen 


118        SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 


Fig.  41.  Schematic  drawing  made  from  a  dissection  of  a  hand  injected  along 
the  tendon  sheath  of  the  ring  finger.  The  mass  filled  the  middle  palmar  space, 
with  extension  along  the  lumbrical  muscle. 


Fig.  42. — Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the 
mass  was  injected  from  the  tendon  sheath  of  the  ring  finger  and  filled  the  loft 
over  the  middle  palmar  space,  but  did  not  rupture  it. 


rxjEcnox  via  tkxdox  siieatii  of  little  fixger    no 

that  the  thinnest  wall  was  in  relation  to  that  space,  and  in 
case  of  infection  the  pus  woukl  have  extended  into  it  in 
all  probability.  (See  experimental  injection  drawing,  Fig. 
42.)  This  is  further  supported  by  Experiments  18,  19, 
and  20  {q.  v.). 

Injection  via  the  Tendon  Sheath  of  the  Little  Finger. 

Experiments  5  and  6  demonstrate  where  the  pus  will 
lie  in  those  cases  in  which  the  rupture  takes  place  in  the 
hand,  namely,  the  middle  palmar  space.  It  may  also 
rupture  in  the  forearm.  In  fact,  that  is  its  most  frequent 
site.  The  location  of  the  pus  in  the  latter  case  will  be 
seen  by  studying  Experiment  47. 

Experiment  5. — During  an  attempt  to  inject  the 
ulnar  sheath  in  the  right  hand  it  was  found  to  be  obliter- 
ated at  the  phalango-metacarpal  articulation.  The  can- 
nula broke  out  into  a  space  which  was  injected  with 
moderate  force,  and  upon  dissection  the  middle  palmar 
space,  as  already  described,  was  found  filled  with  the 
mass.  It  has  not  gone  up  into  the  wrist,  over  into  the 
thenar  or  hypothenar  areas,  but  had  returned  along  the 
lumbrical  muscles  of  the  little,  ring,  and  middle  fingers. 
(See  experimental  injection  drawing,  Fig.  43.) 

Experime?it  6. — In  another  attempt  to  inject  the  ulnar 
bursa  with  moderate  force,  the  injection  was  arrested  at 
the  annular  ligament  owing  to  the  rigidity  of  the  tissue 
of  the  subject.  Due  to  this  fact  and  the  friability  of  the 
tissues  incident  to  age,  the  ulnar  bursa  ruptured  at  about 
the  middle  of  the  palm,  and  the  mass  was  found  to  occupy 
the  middle  palmar  space  only,  in  addition  to  the  ulnar 
bursa  sheath  of  the  tendons.  The  mass  returned  along 
the  ring  finger  lumbrical  only.  The  surgical  importance 
of  this  experiment  is  readily  seen.  (See  experimental 
injection  drawing,  Fig.  44.) 

Experiment  7. — Here  we  have  the  result  produced  in 
those  cases  in  which  the  rupture  is  in  the  forearm  and  not 


120 


SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 


Fig.  43. — Schematic  drawing  made  from  a  dissection  of  a  hand  injected  from 
the  tendon  sheath  of  the  little  finger  with  which  the  ulnar  bursa  did  not  connect. 
The  mass  ruptured  into  the  middle  palmar  space,  filling  it  with  prolongations  along 
three  lumbric^l  muscles. 


Fig.  44. — Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the 
mass  was  injected  along  the  tendon  sheath  of  the  little  finger;  closure  at  the 
upper  end  of  the  annular  ligament  of  the  ulnar  bursa  allowed  rupture  from  the 
ulnar  bursa,  the  mass  filling  the  middle  palmar  space,  with  extension  along  one 
lumbrical  muscle. 


INJECTION  VIA  TENDON  SHEATH  OF  UfTLE  FINGER     121 

in    the    hand.     The   x-ray    photograph    here    presented, 
which  is  made  from  the  hand  injected  in  Exjieriment  7, 


Fig.  45.— X-ray  picture,  showing  the  boundaries  of  the  thenar  and  middle 
palmar  spaces  {MPS)  marked  and  the  proper  site  for  opening  the  latter  indicated. 
The  ulnar  bursa  and  bloodvessels  are  injected.     (See  Exp.  7.) 

presents  a  clear  picture  of  the  bones  in  their  relation  to  the 
injected  bloodvessels  and  ulnar  bursa  (Fig.  45).  Upon 
this  plate  have  been  placed  lines  which   represent  the 


122        SYNOVIAL  SHEATHS  AXD  FASCIAL  SPACES 

boundaries  of  the  thenar  and  middle  palmar  spaces.  The 
numerous  parallel  lines  at  the  distal  end  of  the  palm 
represent  the  dense  tissue  here  overlying  the  articulation, 
in  which  there  are  no  spaces  except  those  made  by  the 
lumbrical  muscles  with  the  vessels  and  the  synovial 
sheaths.  (See  cross-section,  Fig.  28.)  Three  curved  lines 
show  the  position  of  the  flexion  creases  of  the  palm  of  the 
hand,  and  in  relation  to  these,  note  that  the  proximal 
end  of  the  distal  flexion  crease  corresponds  with  the 
beginning  of  the  dense  tissue  noted.  Again,  note  that 
the  distal  end  of  the  middle  flexion  crease  also  begins  at 
the  dense  tissue,  and  hence  a  line  drawn  between  these 
two  points  limits  the  palmar  spaces  distally.  Pay 
particular  attention  to  the  point  at  which  this  middle 
flexion  crease  crosses  the  space  between  the  metacarpal 
bones  of  the  middle  and  ring  fingers,  at  the  distal  end  of 
the  middle  palmar  space,  avoiding  the  thenar  space  upon 
the  radial  side,  the  ulnar  bursa  upon  the  ulnar  side,  the 
dense  tissue  distally,  and  the  deep  palmar  arch  which  is 
seen  crossing  the  upper  part  of  the  middle  palmar  space 
proximally.  Note  that  although  the  injection  mass  has 
broken  from  the  ulnar  sheath  into  the  forearm,  yet  the 
spaces  in  the  hand  are  uninvolved. 

Experiments  54  to  58. — In  these  as  with  many  other 
experiments,  the  records  of  which  are  not  here  reported, 
the  mass  ruptured  at  the  proximal  end  of  the  sheath  under 
the  flexor  profundus  tendons  in  the  forearm.  This  is  the 
most  common  site  of  extension.  (See  Experiment  50 
for  a  complete  description  of  these  cases.) 

Injection  via  the  Tendon  Sheath  of  the  Index  Finger. 

Here  the  findings  are  positive.  In  addition  to  the 
experiment  here  detailed,  many  others  were  performed 
which  gave  the  definite  information  that  when  pus 
ruptures  from   this  sheath   it   enters   the   thenar  space. 


TEXDOX  SHEATH  OF  FLEXOR  LOXGUS  POLLICIS     12:', 

Experiment  8. — Injection  was  made  through  the  tendon 
sheath  of  the  index  finger.  The  mass  occupied  the  thenar 
space;  did  not  go  into  the  forearm  or  middle  palmar  space. 
Passed  around  the  lower  or  distal  edge  of  the  adductor 
transversus,  filled  a  space  the  size  of  a  walnut  between 
that  muscle  and  the  first  dorsal  interosseous,  and  abutted 
on  the  dorsal  subcutaneous  tissue  at  web.  Followed 
index  lumbrical  only.  (See  experimental  injection  draw- 
ing. Fig.  46.) 


Fig.  46. — Schematic  drawing  made  from  a  dissection  of  a  hand  injected  along 
the  tendon  sheath  of  the  index  finger.  Mass  filled  thenar  space  and  extended 
around  to  the  dorsum  underneath  the  adductor  transversus  and  also  along  the 
lumbrical  muscle. 

Experiment  9. — Same  findings  as  in  Experiment  8. 
Experiments  24  to  30  and  29  to  35  corroborate  these 
findings. 

Injection  via  the  Tendon  Sheath  of  the  Flexor  Longus  Pollicis. 

Here  one  would  expect  the  mass  to  enter  the  thenar 
space  in  the  hand,  and  we  were  therefore  surprised  to 
find  that  this  was  not  generally  the  case.     To  determine 


124        SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

this  i)oint  definitely,  eight  experiments  were  made.  In 
each  case  great  pressure  was  used  in  the  injection.  The 
cannula  was  inserted  into  the  tendon  sheath  in  the  thumb 
and  so  bound  that  the  mass  could  not  escape  around  the 
needle.  These  experiments  showed  that  in  a  majority  of 
cases  the  rupture  took  place  into  the  forearm  under  the 
flexor  profundus  digitorum.  It  did  at  times,  however, 
rupture  distal  to  the  annular  ligament  and  fill  the  thenar 
and  even  the  middle  palmar  spaces. 

Experiment  lo. — A  cannula  was  inserted  into  the 
sheath  of  the  flexor  longus  pollicis  at  the  thumb.  The 
injection  mass  was  found  to  have  filled  completely  the 
radial  bursa,  including  the  part  proximal  to  the  annular 
ligament.  The  mass  had  ruptured  from  the  proximal  end 
and  passed  up  into  the  forearm.  No  extravasation  had 
taken  place  into  the  hand,  either  by  direct  rupture  or 
retrograde  extension.  The  attachment  of  the  flexor 
longus  pollicis  at  its  origin  had  been  torn  in  part  from 
the  bone.  The  mass  extended  up  along  this  muscle  on 
the  radial  side  of  the  forearm,  having  on  its  ulnar  boundary 
and  roof  the  flexor  profundus  digitorum  and  the  flexor 
sublimis  digitorum.  The  major  portion  of  the  mass  was 
found  under  the  flexor  profundus  digitorum,  going  over 
even  to  the  flexor  carpi  ulnaris.  It  filled  an  area  extend- 
ing from  the  wrist-joint  to  within  three  inches  of  the 
elbow-joint. 

Experiment  ii. — The  findings  here  were  practically 
the  same  except  that  a  small  part  of  the  mass  passed 
downward  under  the  annular  ligament  and  the  ulnar 
bursa  to  fill  partially  the  middle  palmar  space.  This, 
however,  would  probably  not  occur  in  an  inflammatory 
case  owing  to  the  small  channel  present. 

Experiment  12. — In  this  case  the  mass  ruptured  from 
the  upper  third  of  the  synovial  sheath,  just  distal  to  the 
annular  ligament.  It  extended  downward  to  the  thenar 
space  and  partially  filled  it.     A  small  part  had  also  entered 


TENDON  SHEATHS  AND  FASCIAL  SPACES  125 

the  upper  end  of  the  palmar  space,  owing  to  the  indefinite 
septum  separating  these  spaces  at  the  upper  end.  The 
large  mass,  however,  was  in  the  thenar  space,  but  it 
demonstrated  that  extension  into  the  middle  palmar 
space  would  be  possible  in  neglected  cases. 

Experiments  13,  14,  15,  and  16. — These  were  practically 
duplicates  of  the  above  results. 

Experiment  I'j. — In  this  case  there  was  apparently 
a  free  anatomical  communication  between  the  ulnar 
and  radial  bursa,  for  the  mass  filled  the  ulnar  bursa. 
There  was  also  an  extension  into  the  forearm  from  a 
rupture  of  the  proximal  end  at  the  radial  bursa. 

General  Deductions  as  to  Relation  of  Tendon  Sheaths  to  Fascial 

Spaces. 

The  injections  through  the  synovial  sheaths  of  the 
tendons  of  the  ring  and  middle  fingers  passed  into  the 
middle  palmar  space,  while  that  space  was  reached  also 
from  the  little  finger  in  those  cases  where  the  synovial 
sheath  was  distinct  from  the  ulnar  bursa;  and,  indeed,  the 
contents  of  the  ulnar  bursa  itself,  when  it  ruptured  into 
the  palm,  entered  the  same  space.  Injection  masses  from 
the  index  synovial  sheath  passed  into  the  thenar  space. 
In  those  cases  where  the  synovial  sheath  of  either  of  these 
fingers  communicated  with  the  ulnar  bursa,  the  mass 
passed  into  that,  and  followed  the  course  of  any  bursal 
injection.  The  extreme  rarity  of  communication  between 
the  index  synovial  sheath  and  the  ulnar  bursa  robs  that 
point  of  any  surgical  interest  such  an  anomaly  would  have. 

A  mass  from  the  radial  bursa  or  the  synovial  sheath 
of  the  flexor  longus  pollicis,  if  it  ruptures  into  the  hand, 
will  lie  in  the  indefinite  spaces  mentioned  as  lying  directly 
over  the  muscles  of  the  metacarpal  bone  of  the  thumb 
and  from  thence  into  the  thenar  space.  It  is  possible  for 
the  sheath  to  erode  into  the  thenar  space,  but  it  is  more 
likely  to  rupture  into  the  fascial  spaces  of  the  forearm  and 


120        SYNOVIA/.  SHEATHS  AM)  FASCIAL  SPACES 

lie  under  the  flexor  profiindus  di^itorum.  The  ulnar 
bursa  may  rui)ture  into  the  middle  i)almar  space  and  it 
will  almost  surely  rupture  into  the  forearm  under  the 
flexor  i)rofundus  digitorum. 


THI-:  NORMAL  HOrNDARIES  OF  THK  FASCIAL  SPACES  AND  THE 

POSITION  OF  SECONDARY  ABSCESSES  IN  CASE  OF 

EXTENSION  FROM  THE  SPACES. 

The  Middle  Palmar  Space. 

Injection  via  the  Tendon  Sheath  of  the  Ring 
Finger. — Experiment  i8. — Left  hand,  along  tendon  sheath 
of  ring  finger;  the  mavSs  was  injected  with  considerable 
force.  The  middle  palmar  space  as  described  was  filled. 
Thenar  and  hypothenar  areas  were  free.  The  mass 
followed  along  the  little  and  ring  finger  lumbricals  for 
three-fourths  inch,  ncme  along  other  fingers,  none  through 
between  bones  to  back,  but  it  did  extend  under  the 
tendons,  up  into  forearm,  where  a  large  mass  was  found 
lying  under  the  deep  muscles  upon  the  pronator  quadratus 
and  the  interosseous  septum  up  to  the  pronator  radii  teres. 
The  mass  came  to  the  surface  late  upon  the  radial  side, 
about  two  inches  above  the  wrist,  but  the  mass  was  most 
marked  upon  the  ulnar  side  from  above  downward, 
between  the  flexor  carpi  ulnaris  and  the  deep  tendons  and 
muscles.  The  importance  of  the  position  of  this  mass 
from  a  clinical  standpoint  can  be  seen. 

Experiment   19. — Same  findings  as  in  ii^xi)eriment   18. 

Experiment  20. — Wrist  bound  tightly  above  annular 
ligament;  cannula  inserted  along  ring  finger  synovial 
sheath,  and  mass  injected  with  great  force,  the  idea  being 
to  see  where  the  mass  would  ru])ture  in  case  that  means 
of  exit  was  closed.  None  of  the  mass  went  to  the  forearm 
or  dorsum,  but  did  ru])ture  into  the  thenar  s])ace  at  the 
upper  or  proximal  end  of  the  intervening  septum  and 
filled  the  thenar  space,  passed  along  all  lumbrical  muscles 


THE  MIDDLE  PALMAR  SPACE 


127 


into  canals  for  a  considerable  distance,  but  not  out  into 
the  web  between  the  fingers.  (See  experimental  injection 
drawing,  Fig.  47.) 

Experiments  3  and  4  corroborate  these  findings. 

Experiments  i,  2,  and  3,  in  which  the  space  was  injected 
from  the  middle  finger,  and  Experiments  5  and  6,  in  which 
the  space  was  injected  from  the  little  finger,  present  the 
same  findings  as  in  Experiments  18,  19,  and  20. 


Fig.  47. — Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the 
injection  was  made  along  the  tendon  sheath  of  the  ring  finger  under  great  force. 
The  mass  filled  the  middle  palmar  and  thenar  spaces,  with  extension  along  all 
lumbrical  muscles. 


Injection  through  the  Palmar  Fascia. — Injection 
of  the  space  by  inserting  a  needle  through  the  palm  directly 
into  the  space  gives  the  results  uncomplicated  by  any 
other  process. 

Experiment  21. — Left  hand.  Cannula  inserted  through 
the  palmar  fascia  where  middle  flexion  crease  crosses 
metacarpal  space  between  ring  and  middle  fingers. 
Moderate  force  used. 


128 


SYNOVIAL  SHEATHS  AXD  FASCIAL  SPACES 


Note. — Care  must  be  taken  that  the  cannula  goes 
dorsal  to  the  tendons,  i.  e.,  really  into  space,  otherwise 
the  mass  will  be  confined  to  the  imperfect  spaces  around 
the  tendons,  particularly  su])erficial  to  them.  Even  if 
this  should  occur,  if  great  force  is  used,  it  will  rupture 
into  the  great  space;  not  so  readily,  however,  as  would 
pus,  since  the  erosive  action  of  the  latter  is  not  present  in 
simple  injections. 


Fig.  48. — Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the 
injection  was  made  through  the  palmar  fascia  into  the  middle  palmar  space. 
The  mass  filled  the  middle  palmar  space,  with  extension  along  one  lumbrical 
muscle. 


Upon  dissection  the  mass  was.  found  to  be  limited  to 
what  we  have  found  in  the  middle  palmar  space.  It  was 
limited  upon  the  radial  side  by  the  attachment  of  fascia 
to  the  middle  metacarpal  bone.  This  was  the  long  leg 
of  the  right-angle  triangle.  The  ulnar  side  represented  the 
hypotenuse  of  the  triangle  lying  to  the  radial  side  of  the 
hypothenar  space.  The  apex  of  the  triangle,  or  the  high- 
est point  to  which  the  mass  spread,  was  about  one  inch 


THE  MIDDLE  PALMAR  SPACE  129 

distal  to  the  distal  flexion  crease  of  the  wrist,  or  about  a 
finger's  breadth  proximal  to  a  line  drawn  transversely 
across  the  palm  from  the  w^eb  of  the  extended  thumb. 

At  the  lower  part  of  the  palm,  /.  e.,  toward  the  web  of 
the  fingers,  the  greater  part  of  the  mass  was  limited  by  a 
line  drawn  between  the  radial  end  of  the  middle  flexion 
crease  and  the  ulnar  end  of  the  distal  flexion  crease  of  the 
palm,  or,  roughly  speaking,  about  a  thumb's  breadth 
above  the  web  of  the  fingers;  this  is  the  short  leg  of  our 
right-angle  triangle.  A  prolongation  of  the  mass  had 
taken  place,  how^ever,  along  the  lumbrical  muscle  between 
the  middle  and  ring  fingers,  going  almost  to  the  web  of  the 
fingers.  There  was  no  appreciable  mass  along  the  other 
lumbrical  muscles,  although  some  of  the  strain  from  the 
methylene  blue  used  in  the  injection  mass  had  stained  the 
space  around  the  muscle  leading  to  the  little  finger.  No 
other  prolongations  were  present.  It  did  not  break  into 
the  interossei  muscles  or  superficially  about  the  tendons. 
Superficial  palmar  vessels  crossed  upper  part  of  mass. 
(See  experimental  injection  drawing,  Fig.  30.) 

Experiment  22. — Left  hand.  Injection  at  the  same 
point  and  in  the  same  manner  as  No.  21.  The  mass 
here  occupied  exactly  the  same  area  of  distribution  as  in 
Experiment  21,  except  the  mass  as  a,  whole  was  not  so 
large,  being  a  little  larger  than  an  almond.  The  most 
prominent  part  of  the  mass  was  in  the  middle  of  the  palm, 
over  the  middle  metacarpal  space.  There  were  slight 
prolongations  distally  along  the  lumbrical  muscle  between 
ring  and  middle  metacarpals  as  above. 

Experiment  23. — Injection  made  same  as  in  Experi- 
ment 21.  Both  x-ray  picture  and  dissection  made  of 
this  right  hand.  Mass  extended  somewhat  higher  in  the 
hand  than  in  Experiment  21,  going  to  a  point  about 
a  finger's  breadth  below,  i.  e.,  distal  to  the  distal  flexion 
crease  of  the  wrist  lying  dorsal  to  the  tendon  group; 
laterally  its  boundaries  were  the  same,  while  at  the  distal 
9 


i:30 


SYNOVIAL  SHEATHS  AXD  FASCIAL  SPACES 


portion  of  the  palm  a  prolongation  of  the  mass  occurred 
along  the  lumbrical  muscles  going  to  the  little,  ring,  and 
middle  fingers.  This  is  of  considerable  importance,  since 
it  is  remembered  that  the  relation  of  the  lumbrical  muscle 
of  the  middle  finger  to  the  middle  palmar  space  was 
discussed  in  the  division  devoted  to  cross-sections,  and  this 
experiment    bears   out    the    assumption   hazarded    there 


Fig.  49. — X-ray  plate  made  from  a  hand  in  which  the  middle  palmar  space 
was  injected  with  a  mixture  of  red  lead  and  plaster  of  Paris.  Photograph  repre- 
sents location  of  pus  in  typical  middle  palmar  space  infection. 

that  this  muscle  space  was  really  a  diverticulum  of  the 
middle  palmar  space  and  not  of  the  thenar  space.  (See 
cross-sections.  Figs.  29  and  30.) 

Experiment  24. — Injection  left  hand,  same  as  in 
Experiment  21.  Mass  occupied  same  space  as  Experi- 
ment 2 1 ,  except  that  the  mass  spread  down  along  the  lum- 
brical muscle  of  the  little  and  ring  fingers  for  a  distance 
of  one-third  inch. 


THE  MIDDLE  PALMAR  SPACE 


i:;i 


Injection  THROuciH  Palmar  Fascia  into  Middle 
Palmar  Space. — Experiment  25  (see  x-ray  ])hoto^ra})h, 
Fig.  49). — This  hand  was  also  dissected.  It  demon- 
strates how  the  mass  extends  down  along  the  lumbrical 
muscles,  and  shows  also  what  site  should  he  opened 
to  evacuate  the  contents  of  the  space.  Note  that  the 
hypothenar  and  thenar  regions  are  uninvolved,  the  mass 
not  extending  to  the  radial  side  of  the  middle  metacarpal. 
It  is  seen  that  the  ulnar  bursa  would  lie  over  the  ulnar 
side  of  the  mass. 


Fig.  50. — Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the 
injection  was  made  along  the  lumbrical  muscle  space  between  middle  and  ring 
fingers.     Middle  palmar  space  filled. 


Injection  along  Lumbrical  Muscle  of  Ring  Finger. 
— Experiment  26A. — Cannula  inserted  along  lumbrical 
muscle,  left  hand.  Some  difficulty  was  experienced  in  the 
insertion,  but  when  successful  the  mass  occupied  the 
middle  palmar  space.  There  was  no  return  along  the 
lumbrical  muscles.  Moderate  force  used  in  injection. 
(See  experimental  injection  drawing,  Fig.  50.) 


132        SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

Experiment  26B. — Right  hand.  Same  technique,  injec- 
tion mass  lies  along  lumbrical  muscle.  Middle  palmar 
space  only  partly  filled. 


The  Thenar  Space. 

Note. — The  first  injections  of  this  space  were  very 
unsatisfactory,  owing  to  two  errors  in  technique,  which 
were  corrected  later.  In  the  first  place,  the  injections 
were  not  made  deep  enough;  and  secondly,  they  were  too 
far  to  the  radial  side  over  the  thumb.  It  is  true  that  the 
results  obtained  by  these  injections  were  instructive  in 
that  they  served  to  show  indefinite  limited  spaces  at  these 
sites,  but  they  did  not  reach  the  large  spaces  under 
consideration. 

Injection  via  the  Tendon  Sheath  of  the  Index 
Finger. — Experimejit  27, — Right  hand.  Cannula  insert- 
ed into  tendon  sheath  about  middle  of  proximal  phalanx 
and  ruptured  from  sheath  at  its  proximal  end.  Moderate 
force  used  in  injection.  The  mass  when  dissected  out 
showed  the  limitations  of  the  thenar  space  as  described. 
The  mass  passed  up  dorsal  to  the  tendon,  to  a  thumb's 
breadth  below  the  annular  ligament.  It  did  not  go  to  the 
ulnar  side  of  the  middle  metacarpal.  The  mass  laid 
directly  upon  the  adductor  transversus.  It  did  not  go 
along  the  lumbrical  muscle  to  the  side  of  the  index  finger. 
It  did  not  spread  around  under  the  web  of  the  thumb  to 
the  dorsum  of  the  hand,  but  was  limited  at  the  distal 
border  of  the  adductor  transversus.  It  did  spread  to  the 
back,  however,  at  the  upper  or  proximal  edge  of  the 
adductor  transversus,  going  between  the  adductor  trans- 
versus and  the  adductor  obliquus,  thus  lying  between  the 
adductor  transversus  and  the  first  dorsal  interosseous,  at 
the  distal  edge  of  which  it  came  to  lie  in  the  subcutaneous 
tissue  of  the  dorsum.  (See  experimental  injection  draw- 
ing, Fig.  51.) 


Fig.  51. — Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the 
injection  was  made  along  the  tendon  sheath  of  the  index  finger.  Mass  filled 
thenar  space  and  extended  to  dorsum  between  adductor  transversus  and  adductor 
obliquus. 


Fig.  52. — Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the 
injection  was  made  along  the  tendon  sheath  of  the  index  finger.  Mass  filled  the 
thenar  space  and  extended  along  the  lumbrical  muscle. 


134        SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

Experiment  28. — Injection  same  as  Experiment  27. 
Here  the  mass  did  not  fill  the  space  completely,  but  did 
return  alon^^;  the  lumhrical  muscle  to  the  radial  side 
of  the  index  finger;  condition  well  marked.  For  clinical 
purposes,  Experiments  27  and  28  should  be  studied 
together.  The  probability  is  that  the  cannula  did  not 
rupture  entirely  into  the  space,  but  did  get  out  of  the 
synovial  sheath  into  the  indefinite  spaces  in  the  loose 
connective  tissue  about  the  tendon  above  the  thenar  space. 
(See  experimental  injection  drawing,  Fig.  52.) 

Injection  of  the  Thenar  Space  under  Forcible 
Pressure. — The  index  synovial  sheath  was  opened 
and  cannula  forced  out  of  the  proximal  end  into  the 
palm;  forcible  pressure  with  force  pump  was  maintained 
for  from  three  to  five  minutes.  Owing  to  the  fact  that 
the  routes  of  extension  from  the  thenar  space  were  some- 
what difficult  to  determine  accurately,  nine  injections  of 
the  space  were  made,  with  the  following  results:  In 
none  of  the  cases  did  the  mass  go  up  into  the  forearm.  In 
3  cases  only  did  it  go  into  the  middle  palmar  space.  In  8 
cases  the  mass  passed  dorsal  to  the  adductor  transversus; 
of  these,  in  6  the  mass  went  to  the  dorsum  between  the 
adductor  transversus  and  the  adductor  obliquus,  and  in  4 
passed  below  or  distal  to  the  adductor  transversus  to  lie 
between  the  transversus  and  first  dorsal  interosseous.  In 
no  case  did  the  mass  pass  to  the  dorsum  between  the 
second  and  third  metacarpals. 

Experiment  29. — Left  hand.  Tissues  well  preserved; 
mass  here  occupied  thenar  space,  and  spread  between 
adductor  transversus  and  adductor  obliquus  to  fill  space 
size  of  a  walnut  between  them  and  first  dorsal  interosseous; 
also  ruptured  through  tissues  between  thenar  space  and 
middle  palmar  space  at  the  proximal  end  of  the  septum, 
passed  over  to  fill  the  middle  palmar  space,  and  accom- 
panied the  four  lumbricals  into  their  respective  canals. 
Did  not  go  under  tendons  to  forearm. 


rilE  THENAR  SPACE 


1:55 


Experiments  30,  31,  iiiul  32  were  the  same  as  Experi- 
ment 29,  except  that  the  mass  in  32  (Hd  not  invade  the 
middle  palmar  space.  All  went  above  the  adductor 
transversus  to  dorsum,  however.  The  mass  in  31  passed 
along  the  middle  linger  lumbrical  and  came  to  lie  in  the 
tissue  of  the  web  immediately  beneath  the  web.  (See 
experimental  injection  drawing,  Fig.  53.) 


Fig.  53.— Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the 
injection  was  made  along  the  tendon  sheath  of  the  index  finger.  Mass  filled 
the  thenar  space  and  extended  over  to  the  middle  palmar  space,  along  all  the 
lumbrical  muscles,  and  went  to  the  dorsum,  first  between  the  adductor  trans- 
versus and  obliquus,  and  secondly  between  the  index  and  middle  fingers.  (See 
Fig.  151  for  explanation  of  this  latter  extension.) 

Experiment  33. — ^This  mass  extension  was  extremely 
interesting.  It  filled  the  thenar  space  and  then  passed 
to  the  space  between  the  adductor  transversus  and  the 
first  dorsal  interosseous,  going  both  above  and  below 
the  adductor,  i.  e.,  both  proximal  and  distal,  abutting  on 
the  dorsal  subcutaneous  tissue  at  web  at  distal  edge  of 
first  dorsal  interosseous,  extending  along  index  lumbrical 


136 


SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 


canal,  and  did  not  go  into  middle  palmar  space  or  fore- 
arm. The  most  interesting  extension,  however,  was 
that  which  occurred  through  the  palmar  aponeurosis 
at  the  distal  edge  of  the  bases  of  the  index  and  middle 
fingers  into  the  soft  pad  of  fatty  tissue  which  lies  here 
in  the  palm,  thus  giving  corroboration  to  those  clinical 
cases  which  are  on  record  although  none  have  ever  fallen 
under  my  observation  in  which  pus  has  pointed   here. 


Fig.  54. — Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the 
injection  was  made  along  the  tendon  sheath  of  the  index  finger.  The  mass 
filled  the  thenar  space,  extended  to  the  dorsum  below  the  adductor  transversus 
and  to  the  palm  through  a  defect  of  the  palmar  fascia. 

supposedly  through  an  imperfect  palmar  fascia.  This 
was  the  only  experimental  injection  in  which  a  mass 
appeared  in  the  palm.  (See  experimental  injection 
drawing.  Fig.  54.) 

Experimental  34. — Result  same  as  33  except  no  sub- 
dermal  palmar  extension. 

Experiment  35. — Mass  filled  thenar  space;  no  exten- 
sions except  along  index  lumbrical  canal. 


THE  THENAR  SPACE 


137 


Injection  through  Palmar  Fascia  in  Attempt 
TO  Reach  Thenar  Space. — To  do  this  j^roperly  the 
cannula  should  be  inserted  about  the  middle  line  of  the 


Fig.  55. — Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the 
injection  was  made  through  the  palmar  fascia  into  the  thenar  space. 


Fig.  56. — Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  an 
attempt  was  made  to  inject  the  thenar  space  biit  in  which  the  cannula  reached 
only  one  of  the  indefinite  spaces  near  the  metacarpal  bone. 


138        SVXOVIAL  SHEATHS  AND  FASCIAL  SPACES 

palm  one  centimeter  to  the  thenar  side  of  the  adduction 
flexion  crease  of  the  thumb. 

Experiment  36. — Left  hand.  Cannula  inserted  into 
middle  thenar  space,  moderate  force  used  in  injection. 
Mass  was  found  to  have  filled  the  space  completely, 
but  had  not  followed  along  the  index  lumbrical  muscle 
to  the  finger,  nor  had  it  gone  to  the  dorsum  under  the 
subcutaneous  tissue.  The  space  filled  corresponded  to 
the  area  comprised  between  the  adduction  crease  of  the 
thumb  and  the  metacarpal  bone  of  the  thumb  in  adduc- 
tion.    (See  experimental  injection  drawing,  Fig.  55.) 

Experiment  37. — ^Attempt  to  inject  thenar  space. 
Right  hand.  Cannula  was  inserted  too  far  to  radial 
side  over  muscular  group.  Small  mass  was  found  in 
indefinite  space  adjacent  to  flexor  brevis  pollicis.  (See 
experimental  injection  drawing,  Fig.  56.) 

Experiment  38. — Same  as  Experiment  37. 

The  Dorsal  Subcutaneous  Space. 

Injection  of  Subcutaneous  Tissue  of  the  Dorsum 

BETWEEN     THE     FiRST     AND     SeCOND      METACARPALS. — 

Note. — These  injections  were  made  to  determine  the 
relation  of  these  spaces  to  the  thenar  space  and  the 
remainder  of  the  subcutaneous  tissue  on  the  dorsum. 

Experiment  39. — Injection  right  hand.  Moderate  force; 
insertion  into  subcutaneous  tissue  on  dorsum,  thenar 
region.  Mass  was  found  to  be  subcutaneous,  and  while 
there  was  evidently  a  tendency  to  limitation  at  the  index 
metacarpal,  yet  it  is  doubtful  if  it  was  due  to  the  attach- 
ment of  fascia  to  the  bone,  being  more  likely  to  be  the 
natural  tendency  to  limitation  found  in  the  meshes  of  any 
loose  tissue.  Moreover,  in  spite  of  the  partial  limitation 
at  this  point,  it  had  spread  into  the  subcutaneous  tissue 
above  the  tendons,  going  from  the  wrist  proximally  to  the 
metacarpo-phalangeal  articulation  distally  and  over  to  the 
level  of  the  fourth  metacarpal  bone.  It  did  not  go  through 
to  the  palm  b}^  any  channel. 


TIIK  DORSAL  SUBAPONEUROTIC  SPACE  J:i9 

Experiment  40. — Injection  ol  left  hand  same  as  above. 
Mass  upon  dissection  found  to  occui)y  dorsal  thenar 
subcutaneous  tissue  over  to  the  index  metacarpal,  beyond 
which  it  did  not  extend.  It  did  not  pass  to  the  palmar 
surface  not  into  the  thenar  space. 

Injection  of  the  Subcutaneous  Tissue  of  the 
Dorsum  between  Second  and  Third  Metacarpal 
Bones. — Experiment  41. — Right  hand.  Cannula  inserted 
into  subcutaneous  tissue  of  dorsum  of  hand  and  the  mass 
injected  with  considerable  force.  The  tip  of  the  needle 
was  superficial  to  the  tendons,  but  deeper  than  the  super- 
ficial layers  immediately  beneath  the  skin.  Upon  dissec- 
tion, mass  was  found  to  occupy  a  considerable  space 
extending  from  the  wrist  above  to  the  metacarpo-pha- 
langeal  articulation  below  and  from  the  metacarpal  bone 
of  the  index  finger  to  the  metacarpal  bone  of  the  little 
finger;  proximally  and  distally,  at  the  wrist  and  fingers 
respectively,  the  tissue  seemed  to  be  bound  more  firmly 
to  the  underlying  tissue  than  laterally. 

Experiment  42.— Left  hand.  Technique  and  results 
same  as  Experiment  41.  A  study  of  these  two  show 
several  layers  of  fascia  between  the  skin  and  tendons, 
with  no  single  space  more  distinct  than  another. 

The  Dorsal  Subaponeurotic  Space. 

Injection  Under  Tendons  of  Dorsum. — The  import- 
ance of  this  series  is  seen  when  we  remember  that  it  is 
in  this  space  that  pus  would  lie  if  it  ruptured  through 
between  the  metacarpals  from  the  palmar  surface.  The 
results  obtained  were  uniform. 

Experiment  43. — Left  hand.  Cannula  tip  inserted 
under  tendons  between  middle  and  ring  fingers  at  lower 
third  of  dorsum.  Considerable  force  was  used  in  the 
injection.  The  mass  was  confined  to  the  space  under 
the  tendons,  i.  e.,  was  covered  by  the  tendons  and  the 
aponeurosis  between  them.     It  passed  up  to  the  wrist. 


140         SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

down  to  within  one-half  inch  of  the  fingers,  and  laterally 
to  index  metacarpal  and  little  finger  metacarpal;  thus 
having  the  shape  of  a  truncated  cone  flattened  on  one  side. 
The  mass  appeared  to  be  ready  to  break  out  upon  the 
ulnar  side,  but  none  had  done  so.  (See  experimental 
injection  drawing,  Fig.  57.) 


Fig.  57. — Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the 
injection  was  made  underneath  the  aponeurosis  of  the  dorsum,  the  subapo- 
neurotic space  being  filled. 

Experiment  44. — Left  hand.  Technique  and  results 
same  as  Experiment  43. 

Experiment  45. — Right  hand.  Cannula  inserted 
between  tendons  of  ring  and  little  fingers,  at  the  middle 
of  the  dorsum  of  the  hand;  entire  subaponeurotic  space 
filled;  no  tendency  to  rupture  between  tendons,  but 
evidence  of  beginning  extension  at  two  sides  over  index 
metacarpal  and  little  finger. 

The  Hypothenar  Space. 

Many  experiments  were  made  to  determine  the  limita- 
tions of  this  space.  The  injections  spread  from  the  site 
of  injection  only  after  considerable  manipulation,   and 


RESUME:  OF  EXPERIMENTS  141 

then  the  mass  was  limited  to  the  hypothenar  area,  near 
the  point  of  insertion.  The  details  of  the  other  injections 
are  omitted,  since  they  only  corroborate  the  findings 
already  noted. 

Resume  of  Preceding  Experiments  as  to  Boundaries,  Diverticula,  and 
Extension  from  the  Fascial  Spaces. ' 

That  we  may  have  a  clear  understanding  of  the  results 
obtained  by  experimental  injection,  let  us  summarize 
them.  The  mass  in  the  middle  palmar  space,  in  practically 
every  case,  filled  the  space  we  have  outlined  (Fig.  58). 
In  no  case  did  it  extend  into  the  hypothenar  area  or  to  the 
radial  side  of  the  middle  metacarpal  bone,  except  in  the 
case  noted,  where  a  band  was  tied  about  the  wrist  in  which 
the  mass  then  ruptured  into  the  thenar  space.  In  every 
case  there  was  some  extension  along  the  lumbrical  muscles, 
almost  always  going  down  between  the  bases  of  the  middle 
and  ring  fingers,  and  sometimes  between  the  little  and  ring 

1  A  study  of  the  comparative  embryology  throws  some  Hght  upon  the  natural 
divisions  of  the  hand,  but  unfortunately  this  has  as  yet  only  been  worked  out  in 
relation  to  the  palmar  fascia  and  tendon  groups.  Dr.  McMurrich  (Am.  Jour, 
of  Anat.,  No.  2,  p.  202)  described  the  relation  of  these  in  amblystoma.  The 
muscular  masses  which  here  arise  in  the  palmar  fascia,  and  which  correspond 
to  the  superficial  tendons  in  the  mammalia,  divide  longitudinally  into  three 
groups,  the  lateral  parts  destined  for  the  second  and  fifth  digits,  separating 
from  the  median  parts  destined  for  the  third  and  fourth  digits.  Here  we  see 
that  thus  early  we  have  a  suggestion  of  the  ultimate  relation  of  the  parts,  in 
that  the  tendons  arise  from  the  palmar  fascia  leave  room  below  them  for  fascial 
spaces  between  them  and  the  bones.  And  again,  the  early  grouping  of  the 
tendons  corresponds  to  the  spaces,  i.  e.,  the  radial  lateral  parts  going  to  the 
index  finger,  and  being  entirely  separated  from  the  two  ulnar  parts  correspond- 
ing to  the  middle,  ring  and  little  fingers.  The  most  ulnar  part  is  not  so  dis- 
tinctly separated  from  the  median  part  as  is  the  radial,  that,  in  a  way,  being 
partly  fused  with  the  median,  but  still,  both  upon  dissection  and  injection,  we 
have  noted  a  partial  tendency  to  separation  of  the  middle  and  ring  finger  area 
from  the  little  finger  area.  How  much  the  development  of  the  muscular  mass 
of  the  hypothenar  area  may  have  to  do  with  this  is,  of  course,  undecided,  since 
as  yet  we  know  little  as  to  its  embryological  development,  but  it  would  seem 
reasonable  to  assume  that  it  has  little  relation,  owing  to  its  extreme  ulnar  posi- 
tion; so  that,  reasoning  a  posteriori,  we  would  say  that  in  case  of  the  mammalian 
embryo  there  had  been  a  persistence  of  the  separation  between  the  index  mass 
and  the  others,  while  there  had  been  either  an  incomplete  fusion  between  the 
median  and  ulnar  mass,  or  else  they  had  partially  fused  as  development  proceeded. 


142        SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

fingers,  and,   more  uncommonly,   the  middle  and  index 
fingers.     Unless  great  force  was  used,  this  was  the  limit 


Fig.  58. — Middle  palmar  space.     (X)   Prolongation  of  middle  palmar  space  into 
lumbrical  muscle  space. 


of  the  extension.  When  great  force  was  used,  the  masses 
in  the  lumbrical  canals  passed  out  into  the  loose  tissue  of 
the  web;  also  the  mass  filling  the  space  proper  passed 


RESUME  OF  EXPERIMENTS 


143 


Upward  under  the  tendons  into  the  forearm,  where  it 
spread  beneath  the  dee]:)  muscles  nearly  up  to  the  elbow 
before  it  came  to  the  surface  at  the  lower  part  of  the  fore- 


/ 


p.ilcnar^piiCe;' 


up  Bndon 
Qfiittlefiwer 


Fig.  59. — Showing  extension  of  middle  palmar  space  under  synovial  sheath  of 
little  finger  tendons. 

arm  on  the  ulnar  side.  (For  the  location  of  the  mass  in 
the  forearm,  see  Chapters  X  and  XXVII.)  In  no  case 
did  the  mass  go  through  the  bones  to  the  back. 


144        SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

The  thenar  space  was  found  to  be  a  large  vspace,  but 
lying  very  deep  (Figs.  54  and  55).  It  was  not  continu- 
ous with   the  subcutaneous   tissue  of   the  dorsum,   and 


r^-: 


Forceps  ^n  xhtnar  sp^sS'-'-'^ 


Lumbrical  muscles' 


^  Drditai  branches 
'       >>     -"  cf 'Tned. nerve- 


Deep  toidon     - 
cf  irnhx  Pir^er- 


«5up.  J&ndon  cfwdtx.  finder 


Fig.  60. — Showing  thenar  space. 

the  mass  was  limited  at  the  free  palmar  edge  of  the 
radial  side  of  the  palm.  The  mass  did  pass,  however, 
when  force  was  used,  into  the  perimuscular  sheath  on 
the    dorsum,    passing    proximally    and    less    frequently 


RESUME  OF  EXPERIMENTS  145 

distally  to  the  adductor  transversus,  lying  between  this 
muscle  and  the  first  dorsal  interosseous.  It  also  spread 
down  along  the  lumbrical  muscle  of  the  index  finger, 
making  a  diverticulum  from  one-quarter  to  one-half 
inch  long.  In  no  case  did  it  spread  up  into  the  forearm, 
even  though  anatomical  dissection  demonstrated  that  this 
would  be  possible,  although  improbable,  and  if  it  did  it 
would  be  in  the  same  site  as  that  described  for  masses 
coming  from  the  middle  palmar  space.  In  no  case  did 
the  mass  lie  to  the  ulnar  side  of  the  middle  metacarpal 
bone,  unless  great  force  was  used  in  the  injection;  then  it 
passed  through  the  upper  part  of  the  septum  and  filled  the 
middle  palmar  space  in  one-third  of  the  cases. 

Injections  into  the  hypothenar  area  showed  the  spaces 
to  be  localized  and  perimuscular  for  the  most  part,  not 
communicating  with  any  large  space,  and  hence  of  no 
particular  surgical  importance. 

Injections  of  the  subaponeurotic  space  demonstrated 
that  the  mass  would  not  rupture  through  the  aponeu- 
rosis unless  anatomical  exceptions  were  present.  It 
would  spread  up  to  the  wrist,  down  to  the  metacarpo- 
phalangeal joint,  and  laterally  to  the  edge  of  the  index 
or  little  finger  tendon  on  the  radial  and  ulnar  sides 
respectively.  If  greater  force  were  used,  it  tended  to 
spread  under  the  subcutaneous  tissues,  particularly  on 
the  ulnar  side  and  at  the  knuckles. 

Injections  of  the  dorsal  subcutaneous  space  showed  no 
particular  pockets,  but  did  show  a  tendency  to  localiza- 
tion at  any  site  injected  because  of  the  obliquity  of  fibrous 
bands  crossing  from  space  to  space.  If  the  injections 
were  given  with  great  force,  the  mass  spread  equally  in 
every  direction,  except  that  there  seemed  to  be  some 
particular  factor  at  work  limiting  in  a  certain  measure 
the  spread  of  the  mass  over  the  index  metacarpal  from 
the  dorsum  of  the  hand  to  the  thenar  dorsal  region,  and 
vice  versa. 

lO 


14G         SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

Deep  injections  of  the  palm  went  into  the  spaces  lying 
underneath,  and  since  these  spaces  do  not  overlap,  except 
at  the  wrist,  only  one  space  is  affected  by  a  given  punc- 
tured w^ound.  It  must  be  remembered,  however,  that  the 
lymphatic  channels  from  the  center  of  the  palm  pass 
deeply  into  the  tissue  and  come  to  lie  immediately 
adjacent  to  the  adductor  transversus,  so  that  theoretically 
a  lymphatic  abscess  from  a  punctured  wound  might  lie 
in  the  thenar  area,  although  the  puncture  might  be  at  the 
ulnar  side  over  the  middle  palmar  space  although  I  have 
never  seen  such  an  extension.  When  the  masses  spread 
up  into  the  forearm  they  appeared  under  the  fiexor 
profundus  digitorum.  This  subject  is  considered  as  a 
whole  in  the  next  chapter,  devoted  to  a  study  of  the 
various  spaces  in  the  forearm. 


CHAPTER   X. 

ANATOMY  OF  THE  FOREARM  IN  RELATION 
TO  INFECTIONS. 

Early  in  my  clinical  work  it  was  found  that  there 
was  little  knowledge  as  to  the  sites  of  predilection  for 
pus  in  the  forearm  when  it  extended  from  the  hand. 
Experience  showed  that  incisions  made  at  the  sites  sug- 
gested by  Forssell  and  others  were  followed  by  a  tedious 
convalescence  owing  to  the  necessity  of  maintaining 
satisfactory  drainage  through  the  muscular  bodies.  A 
study  of  the  forearm  after  the  same  methods  already 
pursued  in  the  hand  was  begun,  namely,  the  dissection  of 
serial  sections  and  injection  of  plaster  of  Paris  from 
various  sites.  As  a  result  of  this,  I  changed  entirely  the 
sites  of  my  incisions,  making  two  or  at  most  three,  and  had 
the  great  satisfaction  of  seeing  patients  who  under  the 
old  methods  of  incision  required  weeks  of  constant  atten- 
tion and  multiple  incisions,  heal  in  a  week  to  ten  days. 
Parona,  as  quoted  by  Mauclaire,  has  suggested  the 
advisability  of  one  of  these  incisions — that  upon  the  ulnar 
side  above  the  wrist. 

The  anatomical  and  experimental  data  upon  which 
these  incisions  were  based  are  detailed  in  brief  in  this 
chapter.  . 

ANATOMY  -IN  GENERAL. 

In  general  one  should  remember  that  the  synovial 
sheaths,  i.  e.,  the  ulnar  and  radial  bursae,  pass  under  the 
annular  ligament  and  extend  into  the  forearm  for  a  dis- 
tance varying  from  one  to  two  inches.  The  greater  part 
of  the  sac  of  each  lies  upon  the  dorsal  surface  of  the 
tendons,   /',   e.,   betAveen   the  tendons  of  the  flexor  pro- 


148  ANATOMY  OF  THE  FOREARM 

fundus  digitorum  and  the  pronator  (]uadratus  (Fig.  98). 
Again,  one  should  note  that  the  bloodvessels  and  nerves 
are  surrounded  by  fascial  spaces  and  when  pus  once 
reaches  them  it  can  spread  easily  along  these  as  channels. 
Before  beginning  this  study  one  should  be  familiar 
with  the  general  anatomy  of  the  forearm;  particularly 
the  relations  of  the  flexor  carpi  ulnaris,  of  the  flexor  pro- 
fundus digitorum  as  a  group,  of  the  flexor  sublimis  digi- 
torum as  a  group,  of  the  course  of  the  median  and  ulnar 
nerves,  and  of  the  ulnar  and  radial  artery,  especially  the 
former,  also  the  relation  of  the  pronator  quadratus  and 
the  ulna  and  radius  with  the  interosseous  membrane  in 
one  group  to  the  flexor  profundus  digitorum.  With  these 
general  facts  in  mind,  let  us  now  take  up  the  study  of  the 
cross-sections. 

SERIAL  CROSS-SECTIONS  OF  THE  FOREARM. 

The  cadaver  arms  were  hardened  in  Kaiserling  No.  i. 
After  being  sectioned  the  pieces  were  preserved  in  Kaiser- 
ling No.  2.  Sections  were  made  at  the  following  distances 
from  the  radial  styloid:  3  cm.,  7  cm.,  9  cm.,  and  12  cm. 
The  proximal  surfaces  of  these  sections  were  teased  out 
with  a  needle  and  forceps.  The  large  spaces  found  were 
packed  with  cotton  or  held  open  with  small  props  and 
photographs  taken  to  show  their  relation  to  the  other 
structures  of  the  forearm.  One  particularly  large  free 
space  was  found  in  the  lower  part  of  the  forearm  lying 
between  the  flexor  profundus  group  and  the  pronator 
quadratus.  It  is  upon  this  that  we  will  center  our 
attention. 

Section  i  (Fig.  61). — Three  centimeters  above  radial 
styloid.  The  space  is  rather  small  here,  opening  out 
from  the  narrow  strait  that  connects  it  with  the  middle 
palmar  space  in  the  hand.  It  extends  well  across  the 
forearm,  but  is  slightly  larger  upon  the  radial  side. 
The  vessels  and  nerves  are  separated  from  the  space  by 


SERIAL  CROSS-SECTIONS  OF  THE  FOREARM 


149 


well-defined  layers  of  muscular  and  connective  tissue. 
Upon  the  superficial  surface  it  has  the  tendons  of  the 
flexor  profundus  digitorum,  covered  by  their  synovial 
sheath,  and  the  flexor  longus  pollicis,  covered  by  its 
synovial  sheath.  On  the  radial  and  ulnar  sides  there  is 
nothing  but  the  fascia  attaching  the  flexor  body  of  muscles 
to  the  bones  and  the  subcutaneous  tissue.  On  its  deep 
surface  is  seen  the  pronator  quadratus. 

It  is  seen  that  if  pus  should  rupture  from  the  synovial 
sheaths  or  pass  upward  from  the  middle  palmar  space,  it 
would  enter  this  free  area.  It  is  manifest  that  a  large 
accumulation  could  take  place  here.  Its  most  superficial 
sites  would  be  upon  the  sides. 


^_-._.^-^  4^e^  ;^^ 


Fig.  61. — Section  3  cm.  above  radial  styloid:  UA,  ulnar  artery;  UN,  ulnar 
nerve;  MN,  median  nerve;  RA,  radial  artery;  S,  space;  IM,  interosseous  mem- 
brane; PQ,  pronator  quadratus. 


Section  2  (Figs.  62  and  63). — Seven  centimeters  above 
radial  styloid.  The  relation  of  the  structures  has  not 
changed  materially.  The  body  of  the  pronator  quad- 
ratus is- somewhat  smaller.  The  space  here  goes  well  to 
the  ulnar  side. 

By  comparing  this  with  the  other  sections  it  will  be 
seen  how  little  tissue  lies  at  the  side,  and  it  is  at  this  site 
that  drainage  is  instituted.  The  blocks  of  wood  holding 
open  the  space  are  about  a  centimeter  and  a  half  in 
length. 


150 


l.V.I7'0,l/I*  OF   rilR  I'ORl':.\R.\f 


Section    3    (Fig.    64), — Nine    ecu ti Dieters    above    radial 
styloid.     In    this    section    the    pronator    quadratus    has 


UA 

UN 


PQ 


Fig.  62. — Section  7  cm.  above  radial  styloid:    UA,  ulnar  artery;  UN,  ulnar  nerve; 
MN,  median  nerve;  RA,  radial  artery;  S,  space;  PO,  pronator  quadratus. 


Fig.  63. — Drawing  from  teased  cross-section,  Fig.  62:  a,  e.xtensor  secundi  inter- 
nodii  pollicis;  b,  extensor  communis  digitorum;  c,  extensor  indicis;  d,  e.xtensor 
minimi  digiti;  e,  extensor  carpi  ulnaris;  /,  interosseous  membrane;  g,  ulna;  h, 
pronator  quadratus;  i,  i,  flexor  carpi  ulnaris;  j,  ulnar  nerve;  k,  ulnar  artery;/, 
flexor  profundus  digitorum;  m,  m,  flexor  sublimis  digitorum;  n,  palmaris  longus; 
o,  median  nerve;  p,  fle.xor  carpi  radialis;  q,  flexor  longus  pollicis;  r,  radial  artery; 
s,  space  propped  open  by  pegs  of  wood;  t,  supinator  longus;  u,  extensor  carpi 
radialis  longior;  v,  extensor  carpi  radialis  brevior;  w,  radius;  x,  extensor  primi 
internodii  pollicis. 


SERIAL  CROSS-SECTIOXS  OF  THE  FOREARM         151 

almost  entirely  disai^peared.  The  space  is  bounded 
below  by  the  interosseous  membrane  with  the  artery 
exposed.  The  radial  and  ulnar  arteries  and  the  median 
and  ulnar  nerves  are  still  well  separated  from  the  space. 
Attention  will  be  drawn  to  this  fact  later  in  discussing 
treatment. 


UA 

UN' 


Fig.  64. — Section  9  cm.  above  radial  styloid.  Pronator  quadratus  has  almost 
disappeared.  Notice  that  the  vessels  and  nerves  with  the  exception  of  the  inter- 
osseous {I A)  are  well  separated  from  the  space. 


Fig.  65.— Section  12  cm.  above  radial  styloid.     Note  the  relation  of  the  space  to 
the  median  nerve  and  the  ulnar  artery:   lA,  interosseous  artery. 


Section  4  (Fig.  65). — Twelve  centimeters  above  radial 
styloid.  In  this  section  the  space  is  leaving  the  inter- 
osseous membrane  and  passing  toward  the  flexor  surface 
on  the  radial  side  of  the  deep  flexors.     It  extends  to  the 


152  ANATOMY  OF  THE  FOREARM 

median  nerve  and  over  to  the  ulnar  artery  and  nerve  along 
the  ulnar  side. 

This  relation  of  the  space  to  the  bloodvessels  and  nerves 
explains  why  the  injection  masses  go  up  the  forearm  and 
then  pass  in  a  retrograde  manner  toward  the  hand  along 
these  structures.  It  also  explains  those  cases  in  which 
the  injection  mass  passes  up  along  the  median  above  the 
elbow.  It  helps  to  explain  the  trophic  sequelae  and  cases 
of  ulcerative  hemorrhage  that  have  been  reported.  In 
the  upper  part  of  the  forearm  the  space  follows  the  nerves 
and  bloodvessels  and  becomes  indefinite.  It  is  seen  that 
the  ulnar  nerve  and  artery  along  which  the  secondary 
mass  extends  lie  immediately  under  the  junction  of  the 
flexor  carpi  ulnaris  with  the  flexor  profundus  digitorum 
This  indicates  then  a  second  site  for  incision  (Figs.  133 
and  134.) 

EXPERIMENTAL  INJECTIONS  OF  THE  FASCIAL  SPACES  OF 
THE  FOREARM. 

To  verify  the  findings  here,  experimental  injections 
were  made  with  plaster  of  Paris  from  various  sites  that 
might  be  the  origin  of  spreading  abscesses.  These  will 
show  the  intimate  relation  which  exists  between  the 
fascial  spaces  of  the  hand  and  the  forearm  and  those  about 
the  bloodvessels. 

It  should  be  remembered  that  we  are  only  selecting 
illustrative  experiments  which  bear  upon  the  subject 
in  hand,  and  that  they  do  not  by  any  means  represent  a 
complete  report  of  the  results  obtained  from  injections 
at  these  various  sites. 

Injection  of  the  Radial  Bursa. 

Out  of  the  eight  injections  made  into  the  radial  bursa 
under  high  pressure  to  produce  rupture  and  extravasation 
of  the  mass,  six  showed  extension  from  a  rupture  at  the 
proximal  end  into  the  forearm  (see  p.  124).     The  following 


INJECTION  OF  THE  ULNAR  BURSA  153 

may  be  taken  as  an  example  of  the  condition  found  upon 
dissection  of  the  arm. 

Experiment  46. — Injection  under  great  pressure  of 
synovial  sheath  of  flexor  longus  pollicis  by  plaster  of  Paris. 

Upon  dissection  the  mass  was  found  to  have  filled 
the  synovial  sheath  completely  and  ruptured  from  the 
proximal  end  into  the  tissue  of  the  forearm.  No  extension 
had  taken  place  into  the  hand  either  by  rupture  of  the 
sheath  in  continuity  or  by  retrograde  movement  from 
the  forearm  under  the  annular  ligament,  although  the 
mass  had  extended  down  to  the  annular  ligament  and  lay 
under  the  superior  border.  The  attachment  of  the  flexor 
longus  pollicis  to  the  bone  was  partially  destroyed,  owing 
possibly  to  the  friability  of  the  muscle  in  this  particular 
cadaver,  but  the  mass  showed  a  tendency  to  follow  this 
muscle  and  a  predilection  for  the  radial  side  of  the  forearm. 
A  portion  of  the  mass  laid  between  the  flexor  longus  pollicis 
and  the  flexor  sublimis  digitorum.  The  larger  part,  how- 
ever, extended  underneath  the  flexor  profundus  digi- 
torum to  fill  a  space  bounded  on  the  ulnar  side  by  the 
flexor  carpi  ulnaris,  on  the  radial  side  by  the  flexor  longus 
pollicis,  dorsally  by  the  bones  with  the  interosseous 
membrane  and  pronator  quadratus.  This  extended  up 
to  within  three  inches  of  the  elbow-joint  and  distally  to 
the  wrist-joint.  A  great  amount  of  material  was  present. 
The  area  filled  w^as  practically  that  described  in  the  cross- 
sections,  except  that  the  mass  did  not  extend  between  the 
flexor  carpi  ulnaris  and  the  flexor  profundus. 

Injection  of  the  Ulnar  Bursa. 

Injection  of  the  ulnar  bursa  resulted  frequently  in 
rupture  at  the  proximal  end.  The  mass  showed  a  greater 
predilection  for  the  ulnar  side,  and  had  a  tendency  to 
return  along  the  course  of  the  ulnar  artery.  This  exten- 
sion along  the  vessel  explains  the  presence  of  the  ulceration 
of  the  vessel  and  profuse  hemorrhage  which  occurs  at 
times. 


154  A\A'ir).\fr  OF  rnr.  I'Orkarm 

ExpeHment  47. — Injection  oi  ihc  ulnar  bursa,  rupture 
from   proximal   end,    filling;   deep   space   in    the   forearm 

(Fig.  45)- 

The  ulnar  bursa  was  injected  with  great  force.  Rup- 
ture occurred  at  the  proximal  end;  the  mass  was  found 
to  fill  space  described  above,  being  dorsal  to  the  flexor 
profundus  tendons  and  muscles.  It  showed  a  primary 
predilection  for  the  ulnar  side,  but  returned  along  both  the 
ulnar  and  radial  vessels.  There  was  also  an  extension 
along  the  median  nerve,  this  tongue  of  plaster  following 
the  ner\  e  to  two  inches  proximal  to  the  elbow-joint. 

Injection  from  the  Mid-palmar  Space. 

What  is  the  result  when  the  mass  extends  from  the 
mid-palmar  space  of  the  hand? 

Experiment  48  (Fig.  66). — In  this  case  the  result  is 
shown  by  an  .r-ray  picture.  Both  the  thenar  and  middle 
palmar  spaces  were  injected  with  force  from  the  index 
and  ring  fingers  respectively.  The  thenar  mass  remained 
in  its  usual  compartment,  while  the  middle  palmar  mass 
passed  up  under  the  group  of  flexor  tendons  into  the 
forearm.  Note  the  prolongations  along  the  lumbrical 
muscles,  and  the  thinness  of  the  mass  under  the  site  of  the 
annular  ligament. 

This  graphically  represents  the  theoretical  possibility 
of  an  extension  of  pus. from  the  middle  palmar  space  into 
the  forearm,  but  clinical  experience  demonstrates  its 
infrequency  only  one  such  case  having  ever  fallen  under 
my  observation. 

This  tendency  for  pus  to  extend  along  the  vessels  and 
nerves  helps  to  explain  the  frequency  of  trophic  changes 
which  so  often  occur  as  a  sequence  of  infections  of  the 
hand. 

Experiment  49. — Injection  with  great  force  through 
synovial  sheath  of  the  ring  finger,  filling  mid-palmar 
space  and  extending  under  anterior  annular  ligament  into 
forearm.     (See  experimental  injection  drawing,  Fig.  67.) 


INJECTIONS  FROM   TIIK  M ID-IWf.MAR  SPACE        15:) 

The  mass  Axas  injected  ^\ilh  considerable  force.  The 
middle  palmar  space  as  described  was  tilled.  Thenar 
and   hypothcnar  areas  free,   mass  alon,^   little  and    rini? 


Fig.  66. — X-ray  Plate.  Injection  via  tendon  sheaths  of  both  thenar  and 
middle  palmar  spaces  with  considerable  force.  Note  extension  into  forearm  from 
middle  palmar  space.  Showing  where  pus  would  lie  in  neglected  cases,  as  in 
Cases  XXV  and  XLIV. 


finger  lumbricals  for  three-fourths  inch,  none  along  other 
fingers,  none  through  between  bones  to  back,  mass  extended 
under  tendons  strictly,   up  into  forearm,  where  a  large 


156 


ANATOMY  OF  THE  FOREARM 


mass  was  found  lying  under  the  dee])  muscles  upon  the 
pronator  quadratus  and  interosseous  septum.  1 1  extended 
into  the  intermuscular  fascial  spaces  up  to  the  pronator 
radii  teres,  it  came  to  the  surface  late  upon  the  radial  side 
at  about  two  inches  above  wrist,  but  the  mass  was  most 
marked  upon  the  ulnar  side  from  above  downward 
between  the  flexor  carpi  ulnaris  and  the  deep  tendons  and 


Fig.  67. — Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the 
injection  was  made  along  the  tendon  sheath  of  the  ring  finger.  The  mass  filled 
the  middle  palmar  space  and  extended  along  two  of  the  lumbrical  muscles  and 
under  the  annular  ligament  into  the  forearm.  Clinical  experience  teaches  us 
that  this  is  a  very  uncommon  extension. 

muscles,  so  that  this  upper  mass  was  most  easily  reached 
by  separating  the  flexor  carpi  ulnaris  along  its  volar  edge 
from  the  adjacent  muscular  body.  This  also  exposed 
the  ulnar  artery  and  nerve  which  were  surrounded  by  the 
mass. 

This  is  further  exemplified  by  an  .r-ray  picture  taken  of 
an  arm  injected  as  shown  by  the  legend  (Fig.  66)  the  mass 
being  impregnated  with  red  lead. 


FINDINGS  BY  DISSECTION  AND  INJECTIONS       157 

RESUMfi  OF  FINDINGS  BY  DISSECTION  AND  EXPERIMENTAL 

INJECTIONS. 

By  these  experiments  we  have  demonstrated  that  in 
neglected  cases,  no  matter  whether  the  pus  extends  up 
from  the  ulnar  bursa,  radial  bursa,  or  the  mid-palmar 
space,  the  same  area  of  the  forearm  is  involved,  thus 
indicating  the  position  pus  would  occupy  in  neglected 
cases,  or  in  those  cases  in  which  early  rupture  of  the 
synovial  sheaths  (ulnar  and  radial  bursa)  occurs.  This 
space  lies  under  the  flexor  profundus  digitorum  tendons 


i^S^SSS^ 

! 

^^"d 

f^:^^  ^ 

-N M  N 

M 

1- 

^jjp^ 

'5 

H 

^ 

^^^^^BttL' 

*^ 

wgj 

^ 

1    -^ 

-^ 

m»imm§^j^ 

Fig.  68. — Photograph  of  cross-section,  7  cm.  above  the  radial  styloid,  showing 

area  filled  with  pus. 

and  muscle  (Fig.  68).  About  three  inches  up  on  the 
forearm  the  pus  begins  to  invade  the  intermuscular  septa, 
passing  first  to  the  area  about  the  median  nerve,  and 
later  to  the  area  about  the  ulnar  artery  and  nerve.  Here 
it  lies  between  the  flexor  carpi  ulnaris  and  the  flexor  pro- 
fundus (Fig.  69).  This  is  about  four  to  five  inches  up 
on  the  forearm.  It  may  pass  toward  the  elbow  along  the 
vessels  and  nerves,  particularly  the  median  nerve,  or, 
more  commonly,  it  may  extend  distally  along  the  ulnar 
artery  under  the  flexor  carpi  ulnaris,  and  appear  sub- 
cutaneously  about  three  inches  up  on  the  ulnar  side.     It 


158 


ANATOMY  OF  THE  FOREARM 


may  extend  downward  along  the  radial  artery,  but  this  is 
certainly  an  uncommon  termination.  The  larger  part  of 
the  space  is  about  two  inches  above  the  wrist.  Its  most 
superficial  parts  are  on  either  side,  just  volar  to  the  ulnar 
and  radius.  The  floor  of  the  space  is  made  up  by  the 
pronator  quadratus   at   the  wrist   and   the   interosseous 


Fig.  69. — Photograph  of  forearm  just  below  the  middle,  showing  position  of  pus 
in  its  relation  to  the  ulnar  artery  and  nerve  and  the  median  nerve. 

septum  above.  The  space  may  hold  a  half-pint  or  more 
of  fluid. 

The  only  other  distinctly  separated  space  is  that  com- 
prising the  subcutaneous  tissue. 

(For  the  surgical  application  of  these  facts  see  Chapters 
XXVII  and  XXVIII.) 


SECTION     II. 

THE  SURGICAL  CONSIDERATION  OF  TENDON- 
SHEATH  INFECTIONS  AND  FASCIAL  SPACE 
ABSCESSES  OF  HAND  AND  FOREARM. 


CHAPTER  XI. 

PATHOGENESIS— SOURCE  OF  INVOLVEMENT 

OF  THE  TENDON  SHEATHS  AND 

FASCIAL  SPACES. 

Concerning  the  surgical  application  of  the  anatomical 
and  experimental  data  we  have  discussed  in  the  previous 
chapters,  it  should  be  borne  in  mind  that  our  remarks  are 
strictly  confined  to  a  discussion  of  these  facts  in  relation 
to  the  subject  of  tendon  sheath  and  fascial  abscesses  in  the 
hand.  Lymphatic  infection  will  be  considered  only  m  so 
far  as  it  has  a  distinct  bearing  upon  these  conditions,  a 
full  discussion  being  reserved  for  a  subsequent  chapter. 

ETIOLOGY  IN  GENERAL. 

In  all  of  the  cases  coming  under  observation,  the 
accumulations  of  pus  have  been  submitted  to  bacterio- 
logical examination,  and  the  results  differed  in  nowise 
from  the  findings  elsewhere;' nearly  all  the  slow-growing 
abscesses  showing  the  staphylococcus  in  pure  culture, 
while  those  originating  in  the  tendon  sheaths,  if  of  a 
fulminating  nature,  showed  the  streptococcus  unless 
there  was  a  secondary  infection.  The  severity  of  the 
course  was  often  in   inverse  relation  to   the  extent   of 


100  PATHOGENESIS 

the  primary  wounds.  Again,  the  general  health  and 
resistance  of  the  patient  were  often  below  normal.  The 
latter  factor  has  been  particularly  conspicuous.  On  the 
other  hand,  cases  of  localized  infection  (from  deep  lacer- 
ated wounds)  have  followed  in  very  robust  individuals, 
where  doubtless  the  infection  has  been  carried  directly 
to  the  space  infected.  Again,  it  has  been  noted  that  local 
trauma,  without  apparent  abrasion  of  the  skin,  has  acted 
by  lessening  the  local  resistance,  hence  favoring  infection. 
We  soon  learned  also  that  the  older  the  patient,  the  greater 
would  be  the  danger  of  a  serious  course  and  complications. 
The  gonococcus  may  be  found  in  some  cases,  almost 
always  of  hematogenous  origin. 

SOURCE  OF  INVOLVEMENT  OF  THE  VARIOUS  SHEATHS. 

Attention  has  been  drawn  above  to  the  theories 
advanced  by  the  earlier  authors  as  to  the  source  of 
infection  of  the  sheaths.  It  is  probably  that  they  may 
be  involved  either  by  lymphatic  extension  or  direct 
continuity.  The  latter,  of  course,  needs  no  discussion. 
That  wounds  involving  the  sheath  may  be  an  atrium 
and  that  abscesses  lying  in  continuity  may  cause  necrosis 
and  involvement  will  be  admitted  by  all.  It  is  rather 
uncommon  for  a  felon  unaided  by  ill-advised  incision  to 
give  rise  to  tenosynovitis.  The  same  may  be  said  of 
suppurative  arthritis  of  the  distal  interphalangeal  joint, 
and  the  metacarpo-phalangeal  joint.  This  is  explained 
by  the  anatomical  relations,  which  also  probably  explain 
the  frequent  involvement  from  the  proximal  inter- 
phalangeal joint  (see  pp.  loi  and  102).  I  have  seen 
extension  to  a  sheath  from  abscesses  in  a  lumbrical  canal. 
Here,  however,  the  involvement  is  likely  to  be  localized 
to  the  proximal  end  of  the  finger  sheaths.  Indeed,  this 
holds  true  for  all  of  these  cases  which  develop  as  a  result 
of  abscesses  in  continuity.  One  explanation  of  this  can 
be  found  in  the  fact  that  the  contiguous  inflammation  has 


EXTENSION  FROM  ONE  SHEATH  TO  ANOTHER      UW 

probably  given  rise  to  plastic  adhesions  in  the  sheath 
before  the  actual  involvement  has  taken  place,  and,  again, 
these  local  accumulations  have  generally  been  produced 
by  the  staphylococcus  or  some  like  germ  of  moderate  viru- 
lence. This  is  also  true  of  involvement  of  the  ulnar  or 
radial  sheaths  secondary  to  abscesses  in  the  palm,  as  was 
exemplified  by  the  case  of  Henderson  (see  Case  XVI). 

The  question  of  lymphatic  involvement  is  one  that 
is  not  so  easily  demonstrable,  but  any  surgeon  can  recall 
numerous  histories  of  patients  who  develop  an  infection 
of  a  sheath  within  twenty-four  to  thirty-six  hours  after  a 
simple  needle  prick  of  a  finger  upon  the  volar  surface. 
This  is  most  commonly  met  with  in  the  distal  or  middle 
phalanx  (see  Case  XI),  and  is  almost  always  streptococcic 
in  origin.  Why  it  does  not  occur  in  dorsal  wounds  is 
understood  when  we  remember  that  the  course  of  the 
lymphatic  vessels  is  from  the  palmar  to  the  dorsal  surface. 
Frequently  we  see  cases  of  tenosynovitis  in  which  the 
patient  cannot  give  any  history  of  injury,  the  abrasion  or 
injury  having  been  so  slight  as  to  escape  notice.  It  is  this 
type  of  infection  which  presages  the  most  disastrous 
results,  since  localization  to  any  part  of  the  sheath  is 
uncommon,  and  unless  early  incision  is  instituted,  death 
of  the  synovial  lining  of  the  sheath  takes  place  with 
serious  local  and  constitutional  sequelae.  The  possibility 
of  gonococcus  tenosynovitis  of  hematogenous  origin  must 
always  be  borne  in  mind  in  cases  with  an  obscure  origin. 
Two  such  cases  have  come  under  my  observation. 

EXTENSION  FROM  ONE  SHEATH  TO  ANOTHER. 

The  extension  from  one  sheath  to  another  follows 
strictly  on  anatomical  lines.  Apparent  exception  to 
this  is  found  in  simultaneous  involvement  of  the  thumb 
and  ulnar  bursa  without  involvement  of  the  radial  bursa, 
the  thumb  being  primary,  as  was  found  in  four  of 
Forssell's  cases.     It  is  my  belief  that  such  observations 


162  PATHOGENESIS 

are  generally  an  error  and  that  this  exception  is  very  rare. 
He  did  not  note  any  cases  of  little  finger  infection  and 
radial  bursitis  without  associated  ulnar  bursitis.  In  two 
of  my  cases  I  was  led  to  the  same  conclusion  on  first 
opening  the  sheath  of  the  flexor  longus  pollicis,  but  further 
search  revealed  pus  at  both  ends  of  the  sheath. 

The  anatomical  relations  of  the  finger  sheaths  of  the 
little  finger  and  thumb  to  the  ulnar  and  radial  bursae 
respectively,  as  well  as  the  intercommunication  of  these 
latter,  have  already  been  discussed  (see  pp.  104  and  107). 
When  we  are  dealing  with  an  infection  of  little  virulence, 
such  as  one  due  to  the  staphylococcus,  we  frequently  find 
a  plastic  exudate  or  adhesions  closing  the  narrowed  open- 
ing between  these  parts  and  the  infection  located  in  any 
section;  as,  for  instance,  the  finger  sheath,  ulnar  bursa, 
radial  bursa,  or  the  intermediary  sheaths  at  the  wrist. 
Indeed,  I  have  at  times  seen  an  infection  of  an  ulnar  bursa 
limited  to  that  part  of  the  sheath  between  the  base  of  the 
finger  and  the  annular  ligament,  the  part  of  the  sheath  in 
the  forearm  being  uninvolved,  protected  by  adhesions  at 
the  annular  ligament.  My  experience  here  agrees  with 
the  earlier  observations  of  Schwartz  and  Gosselin,  and 
differs  from  that  of  Forssell,  who  says  that  "out  of  34 
cases  of  ulnar  bursitis,  an  extension  of  the  infection  to  the 
tendon  sheath  of  the  little  finger  was  found  in  30  cases  on 
their  entrance  into  the  hospital,  and  if  we  assume  with 
Poirier  that  the  ulnar  bursa  is  completely  separated  in 
33  per  cent,  of  the  cases,  it  is  very  improbable  that  a 
secondary  boundary  should  in  a  single  one  of  the  afore- 
mentioned cases  have  developed  through  an  adhesive 
inflammation.  ...  I  have  never,  in  operating  upon 
a  suppurative  bursitis,  found  within  the  bursa  proper  a 
fibrinous  or  plastic  synovitis  in  such  a  mass  as  to  notably 
affect  the  operation." 

In  general,  however,  it  may  be  said  that  in  the  virulent 
types  of  infection  beginning  in  the  little  finger  sheath, 


EXTENSION  FROM  ONE  SHEATH   TO  ANOTHER      l(j:j 

we  will  almost  always  have  an  involvement  of  the  ulnar 
bursa  and  in  a  majority  of  cases  the  radial  bursa  and 
sheath  of  the  flexor  longus  pollicis  will  be  involved  from 
it  if  operation  is  delayed  (see  p.  107).  The  converse  is 
also  true.  I  do  wish  to  emphasize,  however,  that  if 
operated  upon  early  an  infection  extending  from  the  radial 
bursa  to  the  ulnar  bursa  will  be  found  very  commonly  at 
that  stage  not  to  have  spread  to  the  tendon  sheath  of  the 
little  finger. 

Besides  spreading  by  direct  continuity  these  infections 
may,  of  course,  involve  one  or  more  sheaths  secondarily 
by  a  rupture  from  a  previously  infected  sheath. 

I  report  the  case  of  Mr.  P.,  who  had  an  infection  of 
the  middle  finger  tendon  sheath  which  extended  by  way  of 
the  lumbrical  canal  over  to  the  tendon  sheath  of  the  ring 
finger,  since  it  demonstrates  the  possibility  of  such  infec- 
tion spreading  to  contiguous  tendon  sheaths,  a  point  that 
has  not  been  brought  out  in  previous  contributions. 

Case  VII.— Mr.  P.,  referred  by  Dr.  A.  T.  Horn. 

History:  Patient  received  slightly  lacerated  wound  on 
the  flexor  surface  of  the  middle  finger.  Inside  of  two  days 
the  finger  was  markedly  swollen  and  tender,  and  when  seen 
in  consultation  on  the  third  day  tenderness  was  marked 
throughout  the  course  of  the  tendon  sheath,  the  finger  was 
flexed  and  on  extension  presented  the  greatest  amount  of 
pain  at  the  proximal  end  of  the  sheath. 

A  diagnosis  of  tenosynovitis  was  made  and  the  tendon 
incised  throughout  its  length.  The  lumbrical  spaces  on  either 
side  were  involved  and  were  drained.  The  infection  appa- 
rently subsided,  but  on  the  seventh  day  it  was  noted  that 
the  ring  -finger  was  markedly  flexed,  tender  throughout  the 
course  of  the  sheath,  and  that  on  extension  pain  was  present 
at  its  proximal  end.  The  diagnosis  of  infection  of  this  sheath 
due  to  contiguity  of  the  lumbrical  space  was  made,  and  the 
tendon  sheath  was  incised  and  drained  by  an  incision  upon 
its  flexor  surface.  From  this  time  on  there  was  an  uninter- 
rupted recovery  as  to  the  infection,  but  the  ultimate  result 
showed  the  patient  with  moderate  flexion  of  the  ring  finger 


164  PATHOGENESIS 

at  Its  proximal  Interphalangeal  joint,  no  motion  at  its  distal 
joint,  and  complete  motion  at  the  metacarpo-phalangeal 
joint.  The  middle  finger  was  held  semiflexed  with  complete 
flexion  at  the  metacarpo-phalangeal  joint;  other  joints  of 
the  finger  could  not  be  moved. 

The  extension  from  the  sheaths  by  rupture  has  been 
discussed  in  the  chapter  on  Experimental  Injections 
(Chapter  IX),  and  will  be  considered  in  the  subsequent 
section  upon  the  course  of  involvement  of  the  fascial 
spaces. 

Exceptionally  the  sheaths  may  become  involved  as  a 
sequence  of  a  systemic  Infection.  Cases  have  come 
under  my  observation  following  both  gonorrhea  and 
puerperal  infection. 

SOURCE  OF  INVOLVEMENT  OF  THE  IMPORTANT  FASCIAL 
SPACES  IN  THE  HAND.     GENERAL  DISCUSSION. 

Involvement  from  the  Tendon  Sheaths. — This 
source  is  certainly  one  of  the  most  common,  and  the 
experimental  and  anatomical  discussions  in  Chapters 
VII,  VIII,  and  IX  had  for  one  of  their  purposes  the 
determination  of  these  facts.  Accepting  the  results  of 
these  investigations  as  probabilities  only,  I  have  been  able 
to  verify  nearly  every  statement  by  clinical  observation. 
In  the  less  virulent  cases  Inflammatory  barriers  may  be 
thrown  out  that  will  close  the  normal  anatomical  canals. 
If  the  process  continues  any  time,  however,  or  the  process 
is  acute,  the  result  follows  absolutely  along  anatomical 
lines. 

The  middle  palmar  space  becomes  involved  secondarily 
to  a  tendon-sheath  infection  of  the  middle,  ring,  and  little 
finger.  At  times  the  middle  finger  tendon  sheath  may 
rupture  into  the  lumbrlcal  space  between  the  index  and 
middle  finger,  and  by  secondary  rupture  may  involve 
the  thenar  spaces.  But  even  in  cases  of  such  a  lumbrlcal 
rupture,  it  generally  Involves  the  middle  palmar  space. 


INVOLVEMENT  OF  FASCIAL  SPACES  IN  HAND      165 

The  thenar  space  is  involved  as  a  result  of  rui)ture 
from  the  tendon  sheath  of  the  index  finder  and  excep- 
tionally from  the  middle  finger.  It  also  occurs  at  times 
that  a  rupture  of  the  flexor  longus  pollicis  sheath  may- 
involve  this  space,  but  here  the  pus  is  more  likely  to  come 
to  the  surface  at  the  web. 

The  htmbrical  spaces  are  most  commonly  the  site  of  the 
primary  focus  after  rupture  from  the  proximal  end  of  the 
various  sheaths.  The  middle  and  ring  fingers  may 
rupture  on  either  or  both  sides.  The  index  finger  most 
commonly  ruptures  to  the  ulnar  side,  but  may  rupture 
upon  the  radial  side,  while  the  little  finger  sheath  ruptures 
only  upon  its  radial  side. 

Infection  of  the  dorsal  tendon  sheaths  is  so  uncommon 
that  prognostic  data  here  would  not  be  of  any  value. 

Direct  Implantation  of  the  Infection  in  the 
Spaces. — ^The  middle  palmar  space  is  infected  by  implanta- 
tion, both  through  direct  puncture  and  extensive  crushing 
injuries  and  lacerated  wounds. 

Case  VI II. — Crushing  injury  of  hand;  fracture  of  ring 
finger  metacarpal,  with  infection  involving  the  middle  palmar 
space. 

Mr.  B.  P.,  aged  twenty- five  years,  Chicago  Charity  Hospital. 

Patient's  Statement:  Patient  states  that  he  was  thrown 
in  front  of  a  moving  car  and  the  wheel  ran  on  his  hand,  but 
evidently  did  not  cross  it.  Condition  found  upon  entrance 
to  hospital  on  following  day:  Lacerated  wounds  across 
dorsum  of  right  hand,  midway;  two  and  one-half  inches  long, 
rather  deep,  into  subcutaneous  tissue;  lacerated  wound  of 
palmar  surface  two  inches  long  and  irregular,  so  that  there 
was  a  flaip  raised  up  consisting  of  tissue  superficial  to  palmar 
aponeurosis;  wounds  infected;  fracture  of  metacarpal  of 
middle  finger;  tendons  intact;  fingers  extended;  not  particu- 
larly tender  to  flexion  and  extension,  although  thumb  was 
more  tender  than  others.  (This  was  later  found  to  be  due 
to  a  fracture  of  the  proximal  phalanx.)  Whole  hand  swollen, 
no  particular  areas.  Flaps  opened  to  allow  drainage.  Hot 
boric  dressings  applied. 


166  PA  THOGENESTS 

Patient's  temperature  and  pulse  demonstrated  a  con- 
tinuation of  the  severe  infection,  and  two  weeks  after  entrance, 
owing  to  the  site  of  the  injury  and  the  greater  rigidity  of  the 
middle,  ring,  and  little  fingers,  a  diagnosis  of  pus  in  the  middle 
palmar  space  was  made.  Proximal  phalanx  extended,  two 
distal  phalanges  flexed  45  degrees  from  the  same  line.  Incision 
into  middle  palmar  space  disclosed  abscess  there  in  communi- 
cation with  the  fractured  metacarpal.  Through-and-through 
drainage  from  palm  to  dorsum  instituted.  Rapid  fall  of 
temperature  and  pulse  followed.  Drainage  was  free.  Edema 
and  swelling  continued  for  some  time,  beginning  to  decrease, 
however,  at  the  end  of  the  first  week. 

January  29  (second  day).  Temperature,  101.5°  to  102^°; 
pulse,  70  to  104. 

January  30.  Temperature,  101°  to  103.25°;  pulse,  80 
to  108. 

February  i.  Temperature,  101.5°  to  101.25°;  pulse,  100 
to  108. 

February  3.     Temperature,  99°  to  99|°;  pulse,  92  to  104. 

February  4.     Temperature,  98^°  to  99.5°;  pulse,  80  to  92. 

February  6.     Temperature,  99.5°  to  102.5°;  pulse,  88  to  92. 

Here  the  infection  evidently  extended. 

February  9.  Temperature,  100.5°  to  ioi|°;  pulse,  84 
to  90. 

February  11.  Temperature,  99.25°  to  104!;°  pulse,  84 
to  92. 

February  13.  Temperature,  100°  to  103.25°;  pulse,  96 
to  124. 

February  15.  Temperature,  100.25°  to  ioi|°;  pulse,  76 
to  90. 

Operation:     Middle    palmar   space   drained. 

February  17.  Temperature,  99.25°  to  100.5°;  pulse,  96 
to  100. 

Temperature  curve  begins  to  fall  and  septic  symptoms 
decrease.    Sleeps  well  and  begins  to  eat. 

February  19.  Temperature,  99.5°  to  101.25°;  pulse,  92 
to  96. 

February  22.  Temperature,  99!°  to  101°;  pulse,  94 
to  96. 

Drain  removed. 

Gradual  fall  until  March  3,  when  the  temperature  fell 
to  normal  and  remained  there. 


INVOLVEMENT  OF  FASCIAL  SPACES  IN  HAND      1G7 

March  20.  Temperature  and  pulse  normal;  hand  still 
swollen  and  little  movement  in  fingers;  position  of  digits 
same  as  upon  entrance;  can  move  all  slightly  without  pain, 
index  most  of  all;  thumb  slightly  tender  to  passive  movements 
(fractured).  Other  fingers:  little  pain  produced  by  manipu- 
lation. 

April  20.  Hand  improved  much;  much  greater  range  of 
movement  of  fingers;  evident  that  nearly  full  functions  will 
be  restored. 

In  deciding,  however,  whether  or  not  the  middle  palmar 
space  has  been  invaded  by  injury,  it  is  well  to  bear  in 
mind  that  the  space  lies  dorsal  to  the  tendons  and  super- 
ficial vessels ;  hence  these  can  be  uncovered  by  a  lacerated 
wound,  and  the  space  not  necessarily  become  involved, 
although  it  is  probably  true  that  unless  scrupulous  care 
be  taken  to  give  perfect  drainage  superficially,  the  space 
will  later  become  involved,  since  the  fascial  sheet  separat- 
ing the  tendons  from  the  space  is  very  thin,  as  has  already 
been  pointed  out.  This  same  fact  is  to  be  remembered  in 
case  of  punctured  wound,  since  while  the  loose  cellular 
tissue  surrounding  the  tendons,  superficial  vessels,  and  the 
lumbrical  muscles  would  harbor  pus  for  a  short  time,  if 
properly  drained  it  need  not  extend  to  the  space.  If 
intervention  is  withheld  for  any  length  of  time  it  must 
extend  either  down  along  the  lumbrical  muscles,  through 
the  fibrous  canal  at  the  distal  part  of  the  palm  already 
noted,  and  thence  into  the  cellular  tissue  dorsal  to  the 
web,  or  break  into  the  palmar  space,  and  in  nearly  every 
case  the  latter  result  will  be  found  to  have  occurred  long 
before  the  former. 

Owing  to  the  juxtaposition  of  the  metacarpal  bones, 
particularly  of  the  middle  and  ring  fingers,  any  crushing 
injury  of  the  hand,  with  consequent  compound  fracture 
of  these  bones,  will  frequently  lead  to  infection  through 
this  dorsal  wound,  as  I  myself  have  seen  (Case  VIII). 
The  metacarpal  bone  of  the  little  finger,  being  somewhat 


168  PATHOGENESIS 

distant  from  the  space,  is  not  so  likely  to  open  the  space, 
while  the  metacarpal  bone  of  the  index  finger  (and  in 
exceptional  conditions  the  middle  finger)  will  open  the 
thenar  space.  Compound  fracture  of  the  thumb  meta- 
carpal would  more  likely  lead  to  dorsal  subcutaneous 
accumulations  of  pus,  or  even  synovial  infection  of  the 
sheath  of  the  flexor  longus  pollicis,  than  thenar-space 
infection.  It  is  well  to  bear  these  predisposing  etiological 
factors  in  mind  when  we  come  to  discuss  the  diagnosis  of 
the  position  of  the  pus. 

Since  few  lymphatics  lead  into  the  hypothenar  space, 
and  it  is  isolated  from  adjacent  areas  by  densely  cir- 
cumscribed tissue,  infection  here  is  due  most  often  to 
direct  implantation.  For  instance,  a  palmar  infection 
will  extend  through  the  lumbrical  canals  to  the  web 
between  the  fingers  or  will  rupture  into  the  ulnar  bursa  or 
in  exceptional  cases  extend,  under  the  annular  ligament, 
and  then  rupture  into  the  cellular  spaces  of  the  forearm, 
before  it  will  overcome  the  resistant  tissue  intervening 
between  it  and  the  h^-pothenar  space  (see  cross-sections, 
Figs.  30  and  31).  The  space  can  be  infected,  however, 
from  the  dorsum,  through  a  compound  fracture  of  the 
fifth  metacarpal,  but  even  there  the  pus  would  be  more 
likely  to  accumulate  upon  the  dorsum,  owing  to  the 
intimate  relations  of  the  hypothenar  muscles  to  the  bone, 
than  to  involve  the  hypothenar  space,  unless  the  injury 
of  the  muscles  is  extensive. 

Direct  infection  of  the  subaponeurotic  space  can  occur 
by  punctured  or  incised  wounds,  or  by  crushing  injuries 
compounded  particularly  upon  the  dorsum.  The  incised 
wounds,  lying  transverse  to  the  tendons,  would  be  less 
likely  to  lead  to  subaponeurotic  accumulations  of  pus, 
owing  to  the  retraction  of  the  aponeurosis  by  the  extensor 
muscles,  thus  opening  the  gap  widely  so  that  free  drainage 
would  ensue  into  the  subcutaneous  tissue  or  externally. 
Longitudinal  cuts,  on  the  contrary,  would  tend  to  close, 
and  thus  prevent  free  drainage. 


INVOLVEMENT  OF  FASCIAL  SPACES  IN  HAND     169 

The  subciitaneoiis  tissue  is  infected  in  the  same  manner. 
It  also  can  be  invaded  in  the  pileous  infections  occurring 
upon  the  dorsum,  which  at  times  become  carbuncular  in 
their  nature,  thus  extending  from  the  skin  proper  into  the 
subcutaneous  tissue. 

Involvement  by  Lymphatic  Extension. — Besides  the 
direct  infection  of  these  spaces,  they  may  become  inxolved 
by  an  extension  from  adjacent  injuries,  either  through 
the  lymphatics,  or  b}'  continuity  of  fascial  spaces.  There 
is  abundant  clinical  proof  that  infection  by  the  less  virulent 
germs  can  spread  by  lymphatic  channels,  and  abscesses 
develop  at  distant  spots.  Upon  the  other  hand,  it  is 
often  impossible  to  sa}'  whether  an  extension  has  occurred 
by  means  of  the  lymphatic  vessels,  or  by  means  of  the 
spaces,  and  fortunately  in  these  cases  it  is  not  necessary 
to  decide  the  question,  since  the  two  courses  are  generally 
side  by  side.  Thus,  the  deep  lymphatics  pass  from  the 
fingers  along  with  the  vessels  in  the  same  space  in  which 
the  lumbrical  muscle  lies,  and  in  a  given  case,  for  instance, 
an  infection  at  the  base  of  the  ring  finger  which  spreads 
into  the  middle  palmar  space,  who  can  say  whether  it 
extends  by  means  of  the  lymph  vessel  or  along  the 
lumbrical  muscle,  going  to  the  radial  side  of  that  finger? 
Moreover,  we  do  not  need  to  know.  What  is  of  import- 
ance is  to  know  where  the  pus  lies  after  it  has  extended,  and 
certainly  a  study  of  the  course  of  the  lymphatic  channels 
is  of  importance  in  relation  to  this.  It  is  not  our  purpose 
to  discuss  the  subject  of  h'mphatic  infection  as  a  whole, 
nor  do  more  than  draw  attention  to  the  monumental 
works  of  Sappey,  Leaf,  Malgaigne,  and  others,  by  which 
we  can,  in  some  measure,  prognosticate  the  position  of  a 
metastatic  abscess  when  the  point  of  primary-  infection  is 
known.  The  subject  as  a  whole  Avill  be  discussed  in  a 
subsequent  chapter. 

The  superficial  h-mphatics  upon  the  palmar  surface 
pursue  the  shortest   course   to   the  dorsum.     Thus,   for 


170  PATHOGENESIS 

instance,  an  infection  starting  upon  the  distal  part  of  the 
pahii  would  go  between  the  web  of  the  fingers  to  the  sub- 
cutaneous tissue  of  the  dorsum.  Hence,  should  an 
abscess  develop  as  a  result  of  this,  it  would  be  found  in 
the  dorsal  subcutaneous  area.  Should  a  lymphangitis 
be  present,  however,  without  localized  abscess  formation, 
the  swelling  in  this  region  would  be  just  as  great,  owing 
to  the  edema  which  develops  in  the  loose  tissue  found 
here.  This  will  be  brought  out  later  in  discussing  the 
diagnosis.  Should  the  deep  lymphatics  be  involved,  the 
infection  will  follow  the  deeper  vessels,  hence  passing  into 
the  palm.  Theoretically  speaking,  then,  an  infection 
spreading  from  the  adjacent  sides  of  the  little  and  ring 
finger,  and  the  ring  and  middle  fingers,  would  lead  to  an 
accumulation  of  pus  in  the  middle  palmar  space,  while  an 
infection  of  the  adjacent  sides  of  the  middle  and  index 
fingers  and  index  and  thumb  would  infect  the  thenar  space. 
Other  infections  upon  these  fingers  more  dorsal  would 
follow  the  deep  vessels  under  the  aponeurosis  upon  the 
back  of  the  hand,  thus  producing  a  subaponeurotic 
abscess.  Unfortunately,  suflficient  clinical  evidence  has 
not  accumulated  to  prove  these  assumptions,  although 
Chevalet  and  Dolbeau,  particularly,  have  presented  cases 
showing  this  complication,  especially  those  showing 
extension  and  development  of  abscesses  under  the  dorsal 
aponeurosis.  The  proof  of  an  extension  to  the  palmar  and 
thenar  spaces  is  much  harder  to  demonstrate,  for  the 
reasons  that  have  already  been  pointed  out.  After  an 
experience  of  over  twenty  years  in  which  I  have  observed 
some  hundreds  of  infected  hands  I  myself,  however,  am 
unable  to  present  a  single  case  in  which  I  could  prove  such 
an  extension  and  it  is  my  personal  opinion  that  secondary 
abscess  in  the  palmar  space  is  seldom  if  ever  due  to 
lymphatic  extension  alone. 

Dolbeau    has   drawn    attention    to    the    frequency    of 
infection  along  the  course  of  the  radial  in  the  forearm, 


INVOLVEMENT  OF  FASCIAL  SPACES  IX  HAND      171 

due  in  his  judgment  to  extension  from  the  thenar  region 
along  the  radial  lymphatics.  He  also  notes  the  presence 
of  abscesses  along  the  ulnar  artery  and  in  the  deep  tissues 
in  the  forearm,  originating,  he  believes,  by  a  lymphatic 
extension  around  the  anterior  interosseous.  That  these 
occur  is  possible;  but  in  this  connection  the  reader  will 
remember  the  experimental  injections  of  the  palmar 
space,  and  the  ulnar  and  radial  bursae  where  the  mass 
spread  by  continuity  of  tissue,  under  the  tendons  into 
the  forearm,  and  then  involved,  secondarily,  both  the 
radial  and  ulnar  areas  mentioned  (Experiments  46  to 
49),  and  this  I  believe  is  the  usual  source  of  such  abscesses. 
I  have  never  seen  one  I  thought  to  be  due  to  lymphatic 
extension. 

Extension  from  One  Fascial  Space  to  Another. 
— In  the  preceding  section  we  have  answered  the  question 
as  to  the  source  of  involvement  of  the  various  spaces. 
We  now  arrive  at  the  next  question  which  confronts  the 
surgeon.  With  a  given  space  already  involved,  to  what 
other  spaces  could  the  infection  extend,  and  by  what 
course?  The  question  now  becomes  one  more  of 
pathology  than  anatomy,  and  while  the  infection  still 
retains  its  full  relation  to  the  anatomical  peculiarities  of  a 
part,  yet  the  destruction  of  tissue  incident  to  long  inflam- 
mation must  be  taken  into  consideration.  The  longer  one 
studies  the  question  the  more  prone  he  is  to  ask  whether 
many  of  the  complicating  extensions  are  not  due  either  to 
inadequate  treatment,  or  an  improper  idea  as  to  the  posi- 
tion of  the  pus,  and  consequently  the  institution  of  inci- 
sions which  tend  to  favor  the  extension  of  the  infection  as 
much  as  to  give  proper  drainage. 

Let  us  take  the  palmar  space.  Here  the  question  of 
extension  has  been  studied  by  injection.  The  pus  would 
have  a  natural  tendency  to  spread  in  two  ways:  First, 
along  the  lumbrical  muscles  of  the. little,  ring,  and  middle 
fingers,  and  thus  point,  in  time,  in  the  connective  tissue 


172  PATHOGENESIS 

of  the  web  upon  the  dorsum.  This  we  know  has  occurred 
in  long-standing  cases,  in  spite  of  the  pseudoclosure  of  the 
canal  at  the  lower  end  and  its  narrowness,  which  would 
thus  favor  closure  by  inflammatory  exudate  (see  .T-ray 
plate,  Fig.  45,  and  schematic  drawings,  Figs.  47  and  51). 
Secondly,  the  pus  may  exceptionally  pass  under  the 
annular  ligament  behind  the  tendons,  immediately  over 
the  wrist-joint,  thence  into  the  forearm,  lying  upon  the 
radius,  ulna,  interosseous  membrane,  and  its  attached 
muscles,  and  the  pronator  quadratus,  covered  by  the 
flexor  profundus  digitorum,  thus  filling  the  entire  space 
from  the  elbow  to  the  wrist  before  it  comes  to  the  surface 
laterally  two  or  three  inches  above  the  wrist-joint  (Experi- 
ment 49).  This  extension  would  take  place  in  at  least 
two-thirds  of  the  injections  of  the  palmar  space  if  force 
were  used.  But  now  enters  the  question  of  destruction 
of  tissue  at  the  wrist-joint,  swelling  of  the  tissues  under 
the  annular  ligament,  and  the  plastic  exudate,  which 
would  tend  to  close  this  natural  exit.  That  this  occurs 
in  a  majority  of  the  cases  we  have  abundant  clinical 
evidence.  I  have  not  had  a  single  case  in  which  pus 
extended  from  the  middle  palmar  space  to  the  forearm, 
but  in  corroboration  of  the  experimental  data  we  find  the 
report  of  a  postmortem  done  by  Professor  Dolbeau,  and 
reported  by  Chevalet  in  his  Paris  thesis  of  1875.  The 
extension  under  the  synovial  sheath,  without  invading  it, 
and  the  involvement  of  the  forearm,  with  diverticulum 
along  the  radial,  all  make  a  picture  the  duplicate  of 
Experiment  49.  It  will  be  noted  that  the  pus  occupies  the 
exact  outlines  of  the  middle  palmar  space,  bathes  the  free 
portions  of  the  tendons  in  juxtaposition  to  the  palmar 
aponeurosis,  and  yet  it  is  specifically  stated  that  the 
abscess  cavity  lay  dorsal  to  the  tendons. 

Case  IX. — "At   the   hand   the   lesion   is   limited   to   the 
middle  palmar  region;  the  two  eminences,  thenar  and  hypo- 


INVOLVEMENT  OF  FASCIAL  SPACES  IN  HAND      \T.\ 

thenar,  are  intact.  In  the  middle  palmar  region  the  apo- 
neurosis is  raised  with  some  difficulty,  the  tissues,  infiltrated 
with  plastic  matter,  form  a  thick  layer  as  if  lardaceous,  in 
the  deep  part  of  which  are  plunged  the  superficial  palmar 
arch  and  the  terminal  ramifications  of  the  median  nerve. 

"These  organs  being  dissected  and  raised,  one  begins  to 
uncover  the  tendons  in  their  palmar  portion,  and  in  order 
to  be  able  to  examine  them  in  their  whole  length,  the  annular 
ligament  of  the  carpus  is  incised. 

"The  sheath  of  the  tendon  of  the  long  flexor  of  the  thumb 
is  intact  in  all  its  length,  at  the  thumb,  at  the  palm  of  the 
hand,  under  the  annular  ligaments,  and  above  this  ligament 
the  cul-de-sac  by  which  it  terminates.  Let  us  recall  that  it 
is  upon  the  thumb  that  the  initial  wound  is  found,  the  point 
of  departure  of  all  the  trouble.  But  the  sheath  of  the  flexor 
longus  poUicis  is  absolutely  intact. 

"In  examining  the  ulnar  sheath  one  finds  the  following: 
The  portion  of  this  sheath  destined  to  cover  the  tendons  of 
the  superficial  flexor  is  little  altered,  and  these  tendons,  save 
that  of  the  little  finger,  are  relatively  intact.  The  portion 
of  the  sheath  destined  to  the  tendons  of  the  deep  flexor  is 
much  more  diseased,  especially  at  the  level  of  the  tendon  of 
the  little  finger.  In  examining  the  sheath  of  this  tendon 
one  finds  it  intact  in  its  digital  portion.  The  tendon  presents 
there  its  mother-of-pearl  appearance,  and  is  absolutely  sound. 
But  if  one  follows  it  to  the  palm  of  the  hand,  one  sees  it  pene- 
trate into  a  purulent  foyer,  which  occupies  the  deep  part  of 
the  hand.  The  tissue  about  bathed  in  pus  is  diseased.  Like- 
wise the  tendons  which  it  envelops  for  a  stretch  of  about 
4  cm.  of  the  tendon  of  the  little  finger,  of  2.5  cm.  to  3  cm.  of 
the  other  tendons,  index,  middle,  and  ring.  Above  this  point 
the  sheath  and  the  tendons  take  again  their  character .  of 
integrity  and  keep  it  in  the  carpal  canal,  even  to  the  terminal 
cul-de-sac -of  the  sheath. 

"In  raising  the  tendons  of  "the  deep  flexor,  one  begins  to 
uncover  a  purulent  foyer  occupying  the  deep  palmar  region, 
situated  exactly  upon  a  median  line  {par  rapport)  in  relation 
to  the  axis  of  the  hand,  and  corresponding  exactly  to  the 
deep  palmar  arch  that  one  sees  placed  against  its  posterior 
wall.  Its  anterior  wall  is  formed  by  the  sheath  of  the  deep 
flexor  tendons  that  it  flooded  over.  It  is  prolonged  the  length 
of  the  sheath  of  the  tendon  of  the  little  finger,  had  opened  it 


174  PATHOGENESIS 

and  pus  had  penetrated  and  traversed  it  in  such  a  manner  as 
to  come  to  show  itself  beneath  the  palmar  aponeurosis;  but  a 
thing  to  notice,  it  had  not  spread  into  this  sheath,  neither 
at  the  lower  part,  toward  the  little  finger,  nor  in  the  upper 
part  in  the  carpal  canal. 

"The  radio-carpal  articulation  is  filled  with  pus;  its  car- 
tilages are  destroyed,  the  osseous  surfaces  which  supported 
them  are  eroded.  The  triangular  ligament  partly  destroyed 
allows  the  radio-carpal  articulation  to  communicate  freely 
with  the  inferior  radio-cubital  articulation. 

"The  articulation  of  the  first  row  of  the  carpal  with  the 
second  is  in  the  same  condition;  likewise  the  articulation  of 
the  bones  of  each  row  between  them,  especially  of  the  first. 
What  is  the  origin,  what  has  been  the  mode  of  production 
of  this  suppurative  arthritis  of  the  wrist?  It  is  a  question 
not  easy  to  decide,  but  that  which  can  be  affirmed  is  that 
the  lesion  so  limited  by  the  sheath  has  not  been  there  for 
nothing,  since  this  sheath  is  intact  at  the  level  of  the  articu- 
lation. 

"In  dissecting  the  forearm,  one  is  struck,  first  of  all  by  the 
apparent  integrity  of  its  anterior  region.  The  lesions  are,  in 
fact,  very  deep.  Alone,  the  sheath  of  the  radial  vessels  appears 
diseased  from  the  first  inspection.  It  is,  in  the  interior  half 
of  the  forearm  region,  infiltrated  with  a  plastic  matter  which 
gives  to  it  the  appearance  of  a  whitened  cord  with  granulated 
surface.  The  artery  plunged  in  the  middle  of  this  plastic 
matter,  is  detached  from  it  only  with  difficulty,  and  by  dis- 
secting it  with  care.  The  sheath  of  the  ulnar  is  intact;  the 
median  nerv^e  presents  nothing  at  all  particular;  the  muscles 
are  intact  also,  at  least  those  of  the  superficial  layers,  because 
in  dissecting  the  deep  flexor  one  finds  beneath  it,  or  rather 
in  its  thickness,  in  front  of  and  inside  of  the  ulnar  bone,  a 
purulent  foyer  of  about  the  volume  of  a  small  egg.  This 
foyer,  situated  at  the  middle  part  of  the  forearm,  well  limited 
below,  at  least  upon  the  anterior  region  of  the  forearm,  is 
without  communication  with  the  lesion  of  the  palm  of  the 
hand,  and,  with  that  which  we  shall  see  presently,  exists  at 
the  level  of  the  pronator  quadratus.  In  seeking  what  has 
been  its  point  of  departure,  one  finds  it  at  the  side  of  the 
ulnar  bone.  This  latter  has  been  the  seat,  in  its  inferior  half 
of  the  suppurative  periostitis,  and  is  almost  totally  denuded, 
even  to  the  middle  of  its  length.    The  foyer  that  we  have  just 


INVOLVEMENT  OF  FASCIAL  SPACES  IN  HAND     175 

indicated  is  a  tributory  of  the  subperiosteal  foyer,  which 
bathes  the  bone  from  the  back  and  the  inside.  The  origin 
of  this  periostitis  appears  to  have  been  the  rupture  of  the 
articulation  full  of  pus,  which  was  opened  from  the  back. 

"In  raising,  at  the  wrist,  all  the  tendons,  the  flexors,  one 
begins  to  uncover  a  second  foyer  situated  between  these 
tendons  and  the  pronator  quadratus.  This  muscle  altered 
but  not  destroyed,  separates  this  foyer  from  the  ulnar  bone, 
so  that  there  exists  no  relation  between  it  and  the  osseous 
lesion.  On  the  contrary,  this  foyer  communicates  by  the 
proper  canal,  behind  the  sheaths  of  the  tendon,  with  the 
palmar  foyer." 

We  now  ask  ourselves.  What  are  the  probabilities 
for  extension  when  these  normal  exits  are  closed?  In 
what  way  will  the  inflammatory  destruction  of  barriers 
show  itself?  The  pus  cannot  break  through  the  firm 
palmar  aponeurosis.  We  first  turn  our  attention  to  the 
adjacent  thenar  space.  We  remember  that  the  lower,  or 
distal  portion  of  the  intervening  wall  is  very  firm,  but  that 
at  the  proximal  end,  the  dividing  tissue  is  rather  thin, 
and  it  is  very  easy  to  suppose  that  the  infection  may 
destroy  this  and  thus  invade  the  radial  side.  Experi- 
mentally, this  can  be  seen  to  occur.  (See  Experiment  20, 
Fig.  47.)  This,  however,  would  not  occur  until  late, 
since  most  of  the  pus  is  at  the  distal  part  of  the  hand. 
But  that  it  does  occur  frequently  in  neglected  cases  I  have 
abundant  clinical  evidence.  It  is  one  of  the  most  com- 
mon of  the  extensions. 

Again,  the  pus  might  extend  along  the  lumbrical  muscle 
of  the  middle  finger,  and  rupture  from  here  into  the 
thenar  area. 

Upon  the  hypothenar  side  there  is  so  much  tissue  inter- 
vening between  the  middle  palmar  space  and  the  hypo- 
thenar that  we  would  expect  this  to  become  involved  only 
in  exceptional  cases. 

Text-books  all  tell  us  that  the  pus  in  these  cases  finds 
exits  between  the  metacarpal  bones,  and  thus  escapes  to 


176  PATHOGENESIS 

the  dorsum.  When  one  studies  the  dense  layer  of  fascia 
spreading  from  bone  to  bone,  upon  both  the  volar  and 
dorsal  surfaces,  being  really  an  anterior  and  posterior 
interosseous  membrane,  with  the  interosseous  muscles 
between,  and  a  division  between  them  being  often  difficult 
to  find,  we  are  led  to  wonder  if  this  complication  really 
occurs  as  early  in  the  course  of  the  disease  as  we  are  led  to 
believe.  Whether  often  the  edema  upon  the  dorsum  may 
not  have  been  mistaken  for  pus,  and  the  spurious  corrobo- 
ration obtained  by  through-and-through  drainage  mis- 
interpreted. By  no  means  can  it  be  denied  that  at  times 
later  in  the  course,  the  pus  does  find  this  means  of  exit. 
When  it  does,  it  first  comes  to  lie  in  the  subaponeurotic, 
and  then  in  the  subcutaneous  tissue.  I  personally  have 
never  seen  such  a  case  unless  there  was  an  osteomyelitis 
of  the  metacarpals  or  carpal  bones,  and  I  believe  it  to  be 
uncommon. 

Another  course  of  extension  is  sometimes  seen  in  which 
the  ulnar  bursal  sheath  is  destroyed,  and  pus  thus  enters 
the  sac,  spreads  along  the  tendons,  and  ruptures  into  the 
forearm  in  the  same  space  we  have  already  described  as 
lying  under  the  flexor  profundus. 

Suppose  the  thenar  space  is  primarily  involved;  the 
pus  here  does  not  so  readily  extend  into  the  forearm. 
(See  Experiments,  Forcible,  Nos.  29  to  33.)  Here  probably 
the  weakest  place  lies  toward  the  dorsum,  either  above  or 
below  the  adductor  transversus,  thus  the  dorsal  sub- 
cutaneous space  becomes  involved  between  the  thumb 
and  index  metacarpal,  and  between  the  adductor  trans- 
versus and  first  dorsal  interosseous,  where  there  is  a  large, 
cone-shaped  cavity.  (See  Experiments  Nos.  29  to  32.) 
It  should  be  borne  in  mind,  however,  that  this  result  is 
not  obtained  easily,  since  the  pus  will  often  remain  for 
days  confined  to  the  thenar  space  (Case  X).  In  long- 
continued  or  anomalous  cases  it  can  spread  up  along  the 
lumbrical   muscle  of   the   index   finger,   infect   the   loose 


INVOLVEMENT  OF  FASCIAL  SPACES  IN  HAND      177 

connective  tissue  about  the  palmar  tendons,  and  thus 
infect  the  pahnar  space,  or  can  rupture  into  the  pahnar 
space  at  the  upper  end  of  the  septum  separating  these 
two  spaces.  (See  Experiments  29  to  35.)  This  compHca- 
tion  should  be  rare,  however,  in  properly  treated  cases. 


Fig.  70. — Scars  showing  where  subaponeurotic  abscess  has  pointed.  Note 
ur  openings  at  the  edge  of  the  aponeurotic  sheet.  Note  prominence  of  tendons, 
e.,  suppuration  b'eneath. 


In  case  the  subaponeurotic  space  is  infected  by  extension 
from  the'  palmar  space  or  otherwise,  there  might  be  con- 
siderable variation  in  the  course  the  pus  would  pursue; 
if  the  sheet  is  dense,  as  it  is  in  a  majority  of  cases,  the 
suppurative  process  would  tend  to  extend  under  the 
aponeurosis  and  point  laterally,  upon  either  side,  at  the 
thinner  tissue  there,  thus  becoming  subcutaneous,  or  at 
the    distal    margin    between    the    metacarpo-phalangeal 


178  PATHOGENESIS 

joints,  as  I  myself  have  seen.  However,  in  some  patients 
the  aponeurosis  will  be  found  to  have  thin  areas  between 
the  tendons,  and  then  the  purulent  matter  would  become 
subcutaneous  through  these  small  openings.  In  all 
probability,  however,  before  any  of  these  things  happen, 
operative  interference  will  have  opened  the  abscess 
(Fig.  70). 

Recapitulation  as  to  Source  of  Involvement  of 
THE  Fascial  Spaces. — Given  a  distinct  space,  from 
what  source,  in  a  majority  of  cases,  is  it  likely  to  become 
involved,  leaving  out  of  consideration  direct  implantation 
of  infection? 

The  middle  palmar  space  would  receive  infection  from 
the  middle  finger,  ring  finger,  and  radial  side  of  the  little 
finger,  with  their  synovial  sheaths  and  the  corresponding 
lumbrical  muscle  spaces.  Osteomyelitis  of  the  middle 
or  ring  metacarpals  would  also  extend  to  this  space. 

The  thenar  space  would  become  involved  by  infection 
from  the  index  finger  and  the  ulnar  side  of  the  thumb  and 
their  synovial  sheaths,  especially  that  of  the  index  finger 
and  the  index  lumbrical  space.  Osteomyelitis  of  the 
index  and  thumb  metacarpals  could  also  involve  this 
space,  although  this  would  be  uncommon. 

The  hypothenar  space  would  become  involved  in  an 
osteomyelitis  of  the  fifth  metacarpal. 

The  subaponeurotic  space  would  become  involved  by  an 
osteomyelitis  of  the  middle  and  ring  finger  metacarpals 
particularly,  and  at  times  from  the  little  and  index 
metacarpals.  Exceptionally  lymphatic  abscesses  might 
develop  along  the  deep  dorsal  vessels  and  would  then  lie 
under  this  sheet  of  tissue. 

The  dorsal  subcutaneous  space  communicates  freely 
with  the  fingers  and  the  thumb. 

The  lumbrical  spaces  would  be  involved  by  extension 
from  a  tendon  sheath  infection  from  either  side  and  from 
an  infection  at  the  web  between  the  fingers  or  a  "collar- 
button"  abscess. 


PATIIOGEXKSfS  170 

R6sum6. 

The  tendon  sheaths  may  be  involved  by  direct  injury 
or  by  lymphatic  extension  from  slight  injuries  upon  the 
volar  surface  of  the  fingers  or  thumb.  Exceptionally  they 
may  be  involved  from  a  systemic  infection. 

Extensions  may  occur  from  one  sheath  to  another  by 
extension  through  a  lumbrical  space  or  other  fascial  space 
abscess. 

The  extension  from  the  little  finger  to  the  ulnar  bursa 
and  then  to  the  radial  bursa,  or  the  sheath  of  the  flexor 
longus  pollicis,  is  well  known  and  frequently  met  with  by 
the  surgeon.  The  reverse  method  of  extension  .is  also 
common. 

Extension  from  one  fascial  space  to  another  may  be 
seen.  Extension  from  the  lumbrical  spaces  to  the  middle 
palmar  and  vice  versa  occurs  very  easily,  while  extension 
between  the  middle  palmar  and  thenar  occurs  only  in 
neglected  cases.  Extension  from  the  lumbrical  space  to 
the  loose  tissue  of  the  web  on  the  dorsum  is  also  common 
in  neglected  cases  but  extension  from  the  palmar  spaces 
to  the  dorsum  between  the  metacarpal  bones  is  very 
uncommon.  Extension  can  occur  from  the  middle  palmar 
space  to  the  deep  spaces  of  the  forearm,  but  this  is  also 
uncommon.  This  extension  is  nearly  always  due  to  a 
rupture  from  an  ulnar  or  radial  bursitis. 


chaptp:r  XII. 

THE  SPREAD  OF  INFECTION  FROM  ANY 
GIVEN  PRIMARY  FOCUS. 

This  will  be  discussed  under  three  heads — the  possible 
spread  from  primary  foci  on  the  fingers,  from  foci  on  the 
palm,  from  foci  on  the  dorsum. 

THE  PROBABLE  EXTENSIONS  FROM  PRIMARY  FOCI  ON  THE 

FINGERS. 

The  Spread  of  Infection  Involving  the  Index  Finger. 

The  index  finger  having  received  a  severe  injury,  caus- 
ing a  deep  infection,  we  admit  that  the  infection  can 
spread  by  three  channels:  (a)  Lymphatic:  (b)  fascial: 
(c)  through  the  synovial  sheath.  The  subject  of  lymphatic 
extension  is  discussed  in  Chapter  XXI. 

Fascial-space  Extension. — The  extension  by  the 
fascial  spaces  is  easy  to  follow  when  we  study  the  series 
of  cross-sections  (Figs.  71  to  78).  By  studying  these  we 
see  there  is  loose  connective  tissue  surrounding  the 
phalanges  in  which  infection  could  spread  with  ease. 
Upon  the  dorsum  it  might  go  up  into  the  subcutaneous 
tissue  in  the  back  of  the  hand,  internally,  it  would  come 
to  lie  in  the  cellular  spaces  at  the  web  between  the  index 
and  middle  fingers,  and  could  ever  spread  along  the 
lumbrical  muscle  of  the  middle  finger  into  the  palm,  and 
thus  invade  the  middle  palmar  space.  This  latter  exten- 
sion, however,  would  be  more  likely  to  occur  in  a  deep 
inflammation  involving  the  proximal  phalanx  of  the 
middle  finger,  if  at  all;  since,  as  a  general  rule,  the  pus 
would  come  to  the  surface  before  extending  along  the 
lumbrical  canal. 


INFECTION  INVOLVING  THE  INDEX  FIXGER        181 


Upon  the  radial  side  of  the  index  finger  there  would  be 
still  less  likelihood  of  the  pus  entering  the  lumbrical  canal 
in  preference  to  coming  to  the  surface,  since  this  canal  is 
not  so  well  marked.  Of  course,  it  could  not  extend  ujwn 
volar  side  into  the  palm,  because  there  is  no  connecting 


Extensor  communis  tendon 
Dorsal  subaponeurotic  space 


,■  Proximal  phalanx 


Subcutaneous  space 


Synovial  sheath 


Flexor  tendon 


Digital  vessels  and  nerves 
Fig.  71. — Cross-section  No.  I.     The  tendon  sheaths  are  shown  in  red. 


Dorsal  subcutaneous  space 
Extensor  communis  tendon 
Digital  vessels  and  nerves 


Dorsal  subaponeurotic  space 
.Jnterossei  muscles 


Lumbrical  muscle 


Epiphysis  proximal 
phalanx 


Lumbrical  muscle 
Flexor  tendon 
Digital  vessels  and  nerves 


Flexor  tendon 

Lumbrical  muscle 


'  Synovial  sheath 

Digital  vessels  and  nerves 

Fig.  72. — Cross-section  No.  II.     Through  epiphysis  of  proximal  phalanx.     The 
tendon  sheaths  are  shown  in  red. 

Space  (see  cross-sections  72  and  74).  Again,  we  note  that 
if  the  pus  were  under  the  dorsal  aponeurosis  of  the  proxi- 
mal phalanx,  it  would  be  limited  to  this  area,  since  it  is  a 
closed  space  and  does  not  communicate  with  the  sub- 
aponeurotic space  upon  the  dorsum  of  the  hand.     Thus, 


182    INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

we  see  that  while  it  is  possible  for  the  thenar  space  to 
become  infected  by  fascial-space  extension  from  the 
index  finger,  it  is  not  probable.     However,  a  metacarpo- 


Articular  surface 
Intcroi>t>ci  miL6clei 


Dorsal  subcutaneous  space 

,  Metacarpal  bone 


m 


»«?.■■  ?>? 


\yi' 


Sesamoid  bone 


Lumbrical  muscle'  I 

Digital  vessels  and  nerves 

Synovial  sheath 


1  Dense  fibrous  tissue 

^Digital  vessels  and  nerves 


Flexor  tendon 


Fig.  73. — Cross-section  No.  III.    Proximal  to  metacarpo-phalangeal  joint. 
The  tendon  sheaths  are  shown  in  red. 


Dorsal  subaponeurotic  space 

Veins  ^  '; 

Extensor  communis  tendon 


Dense  fibrous  tissu 


Dorsal  subcutaneous  space 

Interossei  muscles 

Metacarpal  hone 


Radialis  indicia 


Flexor  tendon^  /  / 

Digital  vessel  arid  nerve  / 

Middle  flexion  crease  '  ; 

Middle  palmar  space ' 


Digital  vessel 
and  nerve 


^-  Thenar  space 

\  ^ 

I  Adductor  transversus  pollicis 

>■ 

Synovial  sheath 


Fig.  74. — Cross-section  No.  IV.     Two  cm.  pro.ximal  to  joint.     The  tendon  sheaths 
are  shown  in  red.     Note  the  beginning  of  the  middle  palmar  space. 


phalangeal  arthritis  may  develop  with  destruction  of 
the  bone  and  ligaments.  This  extension  then  becomes 
not  only  possible  but  probable,  since  the  metacarpal  bone 


INFECTION  INVOLVING  THE  INDEX  FINGER        183 

of  the  index  finger  lies  in  juxtaposition  to  the  thenar  space, 
separated,  however,  in  part,  by  the  adductor  transversus. 
Pus  would  probably  first  enter  the  space  between  the 
adductor  transversus  and  the  first  dorsal  interosseous, 
then  pass  into  the  thenar  space. 

The  question  now  arises,  however,  should  the  pus  lie 
either  primarily  or  secondarily  in  the  subcutaneous  tissue 
upon  the  dorsum  of  the  hand  in  the  region  of  the  index 
metacarpal,  could  it  spread  around  the  radial  border  of 
the  index  metacarpal  into  the  thenar  space?  Again, 
should  it  lie  in  the  subcutaneous  tissue  between  the  index 
and  thumb  metacarpals,  could  it  pass  under  the  web  into 
that  space?  The  study  of  the  cross-sections  (Figs.  75 
and  76)  as  well  as  the  experimental  injections  (Nos.  39 
and  40)  seem  to  show  that  this  is  not  probable.  Clinical 
evidence  can  be  adduced  to  corroborate  this.  The  pus 
would  rather  come  to  the  surface  upon  the  dorsum.  The 
subaponeurotic  accumulations,  unless  complicated  by  an 
osteomyelitis  would  also  follow  the  same  course.  (See 
Experiments,  Figs.  49  to  51.) 

Synovial  Sheath  Extension. — We  now  come  to  the 
third  method  of  extension — by  the  index  synovial  sheath. 
Let  us  suppose  that  the  synovial  sheath  has  become'  filled 
with  pus  and  an  extension  taken  place  into  the  hand  along 
this  sheath.  Here  the  anatomical,  experimental,  and 
clinical  evidence  is  clear.  (See  cross-section.  Figs.  73 
and  74;  Experiments  8,  9,  2j,  and  35;  Case  X.)  Having 
ruptured  from  the  proximal  end  of  the  sheath,  which  is 
very  thin  generally,  the  pus  would  lie  in  the  loose  connec- 
tive tissue  which  surrounds. this  tendon  and  the  lumbrical 
muscle.  After  a  short  time,  as  the  infection  persisted, 
or  the  accumulation  of  pus  grew,  it  would  follow  the 
lines  of  least  resistance,  and  run  along  the  lumbrical 
muscle  toward  the  radial  side  of  the  index  finger  (Experi- 
ment 8,  Fig.  79),  and,  being  limited  here,  would  then 
rupture  through  the  thin  sheet  of  fascia,  separating  this 


184    IXFECTIOX  FROM  ANY  GIVEX  PRIMARY  FOCUS 


Dorsal  subcutaneous  space  ^ 
"Extensor  communis  tendon  ^ 

Dorsal  subaponeu-  _  \ 

rotic  space  \ 

Interosseous  vessels 
and  nerves 

/^ 

Hypothenar  muscles     ^   ^^ir''^ ^^(f^ 
with  intermuscular  -fi^^^^^^^/t '" 
space*  //gf».^^'|^^P*c 


Middle  palmar  spac  > 

Ulnar  bursa' 
Ulnar  vessel  and  nerve 

Flexor  ten/Ion 


Dorsal  interosseous  membrane 

Vein 
I 

Interosseous  muscle 


Space  between  adductor 
transversvs  and  first 
dorsal  interosseous 


~    Radialis  indicis 


Lumhrical  muscle 
Adductor  transversus  pollicis' 


-•->vc,.-^       ^  i-  lexor  longus  pollicis 
Thenar  space 


Palmar  fascia 


Fig.  75. — Cross-section  No.  V.     Three  and  a  half  cm.  proximal  to  joint.     The 
tendon  sheaths  are  shown  in  red  (ulnar  bursa  and  radial  bursa). 


Palmar  interosseous  membrane , 
Dorsal  subcutaneous  space . 
Extensor  communis  tendon 
Dorsal  subaponeu- 
rotic space  "- 
Deep  palmar  arch 


Ulnar  bursa 


Inter ossei  muscles 

Metacarpal  bone 

I  Space  between  adductor 

J     transversus  and  first 
dorsal  interosseous 

Dorsalis  indicia 

,  V      artery 

Metacarpal  bone 
of  the  thumb 


Hypothenar  muscles  g 
with  intermuscular 
spaces 

\ 


Ulnar  vein  <:  ■  i 

Middle  palmar  space 

Median  artery  and  nerve 

Tendon  middle  finger 


Thenar  space 


^    ^  Thenar  muscles 
r  longus  pollicis 

i  ''Aaiiuc[ijr  irurtsversus  poinds 

\Palmar  fascia 
Lumbrical  muscle 


Fig.  76. — Cross-section  No.  \T.     Through  distal  part  of  thenar  area.     The  ulnar 
and  radial  bursae  are  shown  in  red. 


INFECTIOX  INVOLVLXa   rill':  L\DEX  FINGER        185 


Do 


Extensor  communis  tendon        Midflle  palmar  space 
>orsal  subcutaneous  space    ;         }       ■'  '"'"«'■  simce 

f  p.ta''a'''PcJ  hnnj>. 


Dorsal  subaponeurotic  space 
Ulnar  bursa 


Metacarpal  bone- 


Radial  artery 


Hypothenar  musi  Ics 
with  intermuscular 
spaces 


Space  between  adductor 
transversus  and  first 
dorsal  interosseous 


Ulnar  vessels  and  nerve  /  I 

Synovial  sheath  ', 

Flexor  tendon 


I  '.  Thenar  m,uscles 

'  Flexor  longus  poUicis 

Median  nerve  and  vessels 


Fig.  77. — Cross-section  No.  VII.     The  ulnar  and  radial  bursse  and  the  inter- 
mediate tendon  sheaths  are  outlined  in  red. 


Extensor  communis 
Synovial  sheath, 


Extensor  minimi  digiti 


Extensor  carpi  ulnaris 


Hypothenar  muscles 
with  interm.uscular'' 
spaces 


Ulnar  vessels  and  nem 


Extensor  secundi  internodii 
poinds 

Middle  palmar  space 

Extensor  carpi  radialis 
brevior 

''Extensor  carpi  radialis 
longior 
Radial  vessels  and 
nerve 


Extensor  primi 
internodii  pollicia 


Thenar  muscles 


Ulnar  bursa 


I 


\ 


I 


I  Synovial  sheath 

Median  nerve  and  vessels 


Flexor  longus  pollicis 


Paltnaris  longus' 

Fig.  78. — Cross-section  No.  VIII.     The  ulnar -bursa,  radial  bursa,  and  inter- 
mediate sheaths  are  shown  in  red. 


18G    IXFECTIOX  FROM  AXY  GfVEX  PRIMARY  FOCUS 

tissue  from  the  thenar  space  (cross-sections,  Figs.  75  and 
76),  and  thus  become  a  thenar  space  infection.  At  times 
it  may  involve  the  lumbrical  canal  between  the  index  and 
middle  metacarpals.  If  it  spreads  upward  from  here  it 
will  generally  involve  the  thenar  space.  (For  tendon- 
sheath  extensions  see  also  Chapters  IX  and  XI.) 


Fig.  79. — Schematic  drawing  made  from  a  dissection  of  a  hand  injected  along 
the  tendon  sheath  of  the  index  finger.  Mass  filled  thenar  space  and  extended 
around  to  the  dorsum  underneath  adductor  transversus  and  also  along  lumbrical 
muscle. 


The  following  case  corroborates  these  deductions: 


Case  X. — Seen  in  the  service  of  Prof.  F.  A.  Besley  at  the 
Post-Graduate  Hospital. 

Diagnosis. — ^Infected  wound  of  index  finger,  tenosynovitis 
of  index  tendon:  infection  of  thenar  space,  ultimate  amputa- 
tion of  finger. 

September  2,  1904.  T.  W.  Ten  days  before  coming  to 
the  hospital  the  patient  cut  his  finger  just  above  the  knuckle 
joint  on  a  tin  can;  wound  slightly  to  radial  side  of  dorsum. 


IXFECTIOX  IXVOLVIXG  THE  IXDEX  FIXGER        187 

This  became  Infected,  and  the  patient  consulted  a  physician, 
who  opened  the  wound  and  passed  a  drainage  tube  through 
and  across  the  dorsum,  coming  out  between  the  index  and 
middle  lingers.  Upon  examination  the  finger  was  seen  to  be 
much  swollen,  as  was  the  entire  hand,  particularly  the  dorsum. 
Several  openings  appeared  about  the  proximal  phalanx.  A 
probe  into  one  of  these  found  rough  bone  and  easily  entered 
the  knuckle-joint.  The  entire  finger  and  hand  were  slightly 
tender,  but  marked  and  conspicuous  tenderness  was  elicited 
over  the  site  of  the  tendon  sheath,  and  sharpjy  limited  by  it, 
being  most  acute  at  the  proximal  end  over  the  metacarpo- 
phalangeal articulation.  Flexion  of  finger  did  not  increase 
pain;  extension  of  index  finger  caused  marked  pain  through 
finger,  but  most  sharply  noted  by  patient  at  proximal  end 
of  sheath.  Extension  of  other  fingers  caused  little  increase 
of  pain;  no  particular  pain  on  dorsum  of  finger  wheie  cuts 
were  found.  Temperature,  ioi°;  pulse,  92.  Infection  of 
foot  present  also,  as  well  as  small  boil  on  opposite  shoulder. 
Epitrochlear  and  axillary  glands  swollen  out  of  proportion 
to  those  in  left  arm.  (Patient's  resistance  is  evidently  far 
below  par).  Systemic  s3'mptoms  marked.  Neutrophilia,  94 
per  cent. 

Clinical  Diagnosis:  Infected  wound  of  hand;  probably 
staphylococcus;  infected  index  tendon  sheath;  extension  to 
glands  of  axilla  and  elbow  and,  in  addition  infection  of  skin 
on  shoulder  and  in  foot.  Etiology  of  latter  unknown — 
possibly  pyemic  from  hand;  infected  knuckle-joint. 

Prognosis:     Will  probably  lose  finger. 

Operation:  Tendon  sheath  opened  from  end  to  end.  Pus 
in  moderate  amount  evacuated.  Dorsal  openings  previously 
present  enlarged.  Hot  boric  dressings.  Foot  opened  and 
drained.    Temperature  ran  99°  to  101°  every  day. 

September  9.  Finger  shows  fluctuation  on  dorsum  of 
hand  just  proximal  to  index  finger  and  ulnarly.  Incision 
and  drainage.  Finger  not  so  painful;  flexion  about  same. 
Not  so  tender;  no  special  swelling  in  palm  of  hand. 

September  12.  Infection  has  extended  to  thenar  eminence; 
tenderness  localized  to  this  area.  Swelling  marked;  palm 
not  involved. 

Operation:  Inserted  forceps  into  cut  on  dorsum  made 
September  9;  forceps  fell  into  direct  communication  with 
A'olar  surface  of  thenar  eminence ;  opened  here ;  pushed  forceps 


188    INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

then  from  volar  surface  through  to  dorsum  between  first  and 
second  metacarpals;  forceps  passed  through  dorsal  skin  with 
little  or  no  resistance;  drainage  inserted. 

September  15.  Subcutaneous  abscess  has  developed  in 
radial  region  of  forearm  above  wrist  and  above  elbow,  and 
over  brachial  vessels;  incised  and  drained.  White-blood 
cells,   18,000. 

September  24.     Temperature,  99°  to  101°. 

October  14.  Temperature  has  been  running  99°  to  100° 
for  last  two  weeks;  index  finger  swollen  to  four  times  its 
normal  size;  blue,  and  evidently  there  is  an  osteomyelitis  of 
the  proximal  phalanx,  and  a  suppurative  arthritis  of  the 
metacarpo-phalangeal  joint. 

Operation:  Index  finger  and  head  of  metacarpal  bone 
amputated;  drainage. 

October  20.     Condition  of  hand  much  better. 

Following  this  the  patient  improved  rapidly;  discharged. 

November  3,  1904.  Small  area  of  granulation  tissue  over 
amputated  area;  moves  thumb  and  three  fingers  three- 
fourths  of  normal;  wrist-joint  same;  function  of  all  will 
ultimately  be  restored. 

The  Spread  of  Ixfection  Involving  the  Thumb. 

Infection  of  the  thumb  would  at  first  glance  seem  to 
offer  the  most  favorable  course  for  pus  to  extend  into  the 
thenar  space.  But  let  us  consider  for  a  moment.  Lym- 
phatic extension  does  offer  some  chance,  if  the  infection 
be  deep  and  upon  the  ulnar  side,  as  will  be  pointed  out 
(Chapter  XX,  and  Fig.  116).  Upon  the  other  parts, 
however,  the  tendency  would  be  for  the  pus  to  be  carried 
away  from  the  space. 

The  synovial  sheath  of  the  fle.xor  longus  pollicis  lies 
some  distance  from  the  space,  and  hence  pus  would  tend 
to  come  to  the  surface  if  the  sheath  ruptured  in  its  course. 
It  can  be  seen,  however,  that  if  the  sheath  ruptured  in  its 
distal  part,  and  the  infection  thus  became  an  infection  of 
the  connective-tissue  spaces,  it  could  spread  along  the 
ulnar  side  of  the  thumb,  and  by  considerable  destruction 
of  connective  tissue  come  to  lie  upon  the  origin  of  the 


SPREAD  OF  TNPRCTION  INVOLVING  MIDDLh:  FINGER    1S<) 

addiirlor  Ininsversus,  and  thus  invade  the  space.  In  the 
majority  of  cases,  however,  the  pus  would  rupture  from 
the  sheath  into  the  forearm.  (For  further  discussion  of 
tendon-sheath  extensions,  see  Chapters  IX  and  XIV.) 

Should  the  infection  be  upon  the  back  of  the  thumb, 
the  pus  would  extend  more  easily  into  the  dorsal  sub- 
cutaneous tissue  of  the  thenar  area,  while  in  all  prob- 
ability, upon  its  radial  side  it  would  point  upon  the 
surface. 

The  Spread  of  Infection  Involving  the  Middle  Finger. 

Here  the  finger,  lying  as  it  does  in  the  dividing  line 
between  the  thenar  and  middle  palmar  spaces,  becomes 
an  extremely  interesting  subject  of  study.  The  lym- 
phatic extension  has  already  been  touched  upon  and  will 
be  discussed  further  in  Chapters  XX  to  XXIV. 

Extension  from  the  synovial  sheath  at  its  proximal 
end  gives  positive  results  experimentally  (Experiments 
I  and  2),  since  in  every  case  the  mass  extended  into  the 
middle  palmar  space  after  rupturing  through  the  indefinite 
connective  tissue,  separating  it  from  the  space,  as  already 
described  under  the  index  finger  discussion.  It  is  to  be 
borne  in  mind,  however,  that  the  lumbrical  muscle  joining 
this  tendon  comes  back  to  pass  under  the  transverse  liga- 
ment, between  the  index  and  middle  fingers,  and  that 
while  the  tissue  intervening  between  this  muscle  and  the 
thenar  space  is  firm,  and  experimental  injections  have 
failed  to  rupture  through,  yet,  anatomically,  it  would 
seem  to  be  possible  in  some  cases.  Clinical  evidence 
shows  that  while  it  does  occur  this  extension  is  rare.  For 
a  complete  discussion  of  the  extensions  from  the  tendon 
sheaths,  see  Chapters  IX  and  XIV.  Should  the  infec- 
tion be  a  deep-seated  accumulation  of  pus  in  the  cellular 
tissue  upon  the  dorsum  it  could  spread  subcutaneously 
upon  the  back  of  the  hand;  upon  the  radial  side  it  would 
pass  exceptionally  along  the  lumbrical  muscle  into  the 


100    IXFECTIOX  FRO}r  A XV  GIVEX  PRIMARY  FOCUS 


Fig.  80. — Schematic  drawing  made  from  a  dissection  of  a  hand  injected  from 
the  tendon  sheath  of  the  middle  finger.  The  mass  filled  the  middle  palmar  space 
and  extended  along  the  two  lumbricals. 


Fig.  81. — Schematic  drawing  made  from  a  dissection  of  a  hand  injected  along 
the  tendon  sheath  of  the  ring  finger.  The  mass  filled  the  middle  palmar  space, 
with  extension  along  the  lumbrical  muscle. 


INFECTION  INVOLVING  THE  RING  FINGER         101 

middle  palmar  space,  with  the  possibility  of  invading  the 
thenar  space,  as  above  noted;  upon  the  ulnar  side,  if  it 
should  spread  along  the  lumbrical  muscle,  it  would  go  into 
the  middle  palmar  space  (Experiments  26A,  and  26B). 

Subaponeurotic  infection  would  be  limited  to  the 
phalanx,  while  osteomyelitis,  involving  the  metacarpal 
bone,  would  tend  to  invade  the  middle  palmar  space  in 
front  and  the  subaponeurotic  on  the  back. 

The  Spread  of  Infection  Involving  the  Ring  Finger. 

Here  there  is  little  doubt  about  the  relation  between 
this  finger  and  the  middle  palmar  space.  The  extension 
by  the  dorsal  subcutaneous  tissue  may  be  in  any  direction. 
The  connective-tissue  spaces  at  either  side  of  the  finger 
and  in  the  web  of  the  infected  hand  allow  the  pus  to 
spread  through  the  fibrous  canal  surrounding  the  lumbri- 
cal muscles  and  lead  into  the  palmar  space.  (See  Experi- 
ments 26A  and  26B,  and  Fig.  26.)  In  making  this  deduc- 
tion it  should  be  emphasized  again  that  in  a  majority  of 
cases  pus  would  be  evacuated  on  the  surface  before  it 
would  burrow  through  this  canal.  Hence  it  is  only  in 
neglected  cases  that  this  complication  would  ensue,* 
unless  extension  had  taken  place  by  the  lymphatic  chan- 
nels which  pass  through  these  same  canals  a  very  rare 
complication  in  my  experience. 

Suppuration  extending  from  the  synovial  sheath  would 
enter  the  middle  palmar  space.  (See  Experiments,  3, 
4,  18,  19  and  20;  cross-sections,  Figs.  75  and  76.)  Pri- 
marily, of -course,  it  would  lie  in  the  loose  connective  tissue 
superficial  to  the  space,  spread  down  along  the  lumbrical 
muscles  (Fig.  42),  especially  of  the  little,  ring,  and  middle 
fingers,  and  then,  destroying  the  thin  roof  of  the  space, 
would  involve  the  entire  middle  palmar  space  (Fig.  81). 
(For  a  complete  discussion  of  tendon-sheath  extensions, 
see  Chapters  IX  and  XIV.) 

Arthritis  of  the  metacarpo-phalangeal  joint,  with  osteo- 


192     INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

myelitis  of  the  diaphysis  of  the  metacarpal,  could  also 
infect  this  space  as  well  as  the  subaponeurotic  on  the 
dorsum  (Case  VIII). 

(The  lymphatic  extension  will  be  discussed  in  Chapters 
XX  and  XXI.) 

Infection  Spkk.vding  i-kom  the  Little  Fingek. 

Here  the  lymphatic  channels  and  connective-tissue 
spaces  upon  the  inner  side  of  the  hnger  c^^l  lead  into  the 
middle  palmar  space,  although  suc^^^tension  is  uncom- 
mon. On  the  outer  and  dorsal  sicla^Piey  would  tend  to 
lead  into  the  subcutaneous  tis^e  externally. 


Fig.  82. — Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the 
mass  was  injected  along  the  tendon  sheath  of  the  little  finger;  closure  at  the 
upper  end  of  the  annular  ligament  of  the  ulnar  bursa  allowed  rupture  from  the 
ulnar  bursa,  the  mass  filling  the  middle  palmar  space,  with  extension  along  one 
lumbrical  muscle. 

The  synovial  sheath,  if  continuous  with  the  ulnar 
bursa,  would  probably  rupture  earliest  in  the  forearm. 
(See  .T-ray  plate,  Fig.  45).  (For  a  discussion  of  this,  see 
Cheipters  IM  and  XIV.)      If  it  did  rupture  into  the  hand, 


3yn( 


or  if  the  synovial  sheath  of  the  finger  were  shut  off  from 
/ 


INFECTIONS  BEGINNING  IX  PALM  AND  DORSUM      193 

the  ulnar  bursa,  and  the  finj^cr  sheath  ruptured,  it  would 
tend  to  involve  the  middle  palmar  space.  (See  Experi- 
ments 5  and  6,  F'v^.  82).  It  might  be  mentioned  here 
that  Chcvalet  and  Dolbeau  maintain  that  a  rupture  of  the 
sheath  is  not  necessary  to  extension  but  that  this  can  take 
place  from  the  sheath  by  lymphatic  extension,  and  they 
adduce  a  postmortem  examination  in  support  of  their 
contention.  TJ^s  however,  is  an  academic  question, 
since  the  sam^^ace  would  be  involved  by  the  extension, 
l^^i 

Chapters  IX  and  XI Y.)^ 

If  an  osteomyelitis  of  the  fifth  metacarpal  be  present 
the  hypothenar  space  jy^Pt  be  involved  upon  the  volar 
surface  and  the  subc^Hieous  tissue  dorsally.  (See  cross- 
sections,  Figs.  75  arB  76.) 


and    the   clinical ^jjdings   would    be   identical.     (For   a 
complete  discuss^^of  the  tendon-sheath  extensions,  see 


Infections  Beginning  in  the  Palm  and  Dorsum. 

When  a  primary  focus  appears  upon  the  palm,  if  it 
is  a  punctured  wound,  the  abscess  may  develop  in  any  of 
the  pockets  I  have  described,  if  implanted  there  under  the 
palmar  fascia.  If  in  the  superficial  thenar  or  hypothenar 
area,  they  may  develop  local  abscesses  without  entering 
the  palmar  or  thenar  spaces.  If  the  infection  develops 
at  the  distal  part  of  the  palm  in  the  subcutaneous  tissue 
or  in  the  lumbrical  space,  i.  e.,  a  "frog  felon,"  "collar- 
button"  abscess  (see  Chapter  IV),  and  if  extension  occurs 
it  will  generally  be  to  the  dorsum  between  the  bases  of  the 
fingers,  although  occasionally  proximally  along  the  lumbri- 
cal canals  into  the  middle  palmar  space,  if  between  the 
little  and  ring  fingers^or  into  the  thenar  space  if  between 
the  middle  and  index  fingers.  In  the  central  part  of  the 
palm  it  is  not  possible  for  large  abscesses  to  develop 
between  the  skin  and  the  palmar  fascia,  owing  to  their 
intimate  association.  ^ 

Lymphatic  infections  in  the  central  par^Df  the  palm 
13 

v 


194    INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

may  involve  the  deeper  part  of  the  hand  although  I  have 
never  seen  it  occur  (Fig.  ii8).  At  the  sides  the  infection 
pursues  the  shortest  course  to  the  back  of  the  hand,  where 
abscesses  may  develop  subcutaneously.  At  the  proximal 
end  of  the  palm  secondary  lymphatic  abscesses  may 
develop  subcutaneously  above  the  anterior  annular 
ligament.     (See  Chapter  XIV.) 

Middle  palmar  and  thenar-space  abscesses  are  generally 
secondary  and  are  discussed  elsewhere  in  detail. 

When  the  primary  focus  develops  upon  the  dorsum, 
if  it  be  a  localized  abscess,  it  will  be  either  in  the  sub- 
cutaneous or  subaponeurotic  spaces.  If  extension  takes 
place  by  contiguity  or  lymphatic  channels,  the  secondary 
abscesses  lie  upon  the  dorsum  of  the  forearm  or  the 
glandular  area  at  the  elbow  and  axilla. 

Resume. 

Infection  may  spread  in  one  of  three  ways:  by  a  lym- 
phatic canal,  by  a  fascial  space,  or  through  a  synovial 
sheath. 

If  the  infection  in  the  index  finger  spreads  by  the  fascial 
spaces,  the  pus  will  lie  in  the  connective  tissue  at  the  web 
of  the  index  and  middle  finger,  whence  it  may  spread 
along  the  lumbrical  muscle  into  the  palm. 

In  any  other  part,  the  pus  will  lie  underneath  the  skin 
and  will  soon  come  to  the  surface. 

The  proximal  interphalangeal  joint  will  be  involved 
more  often  than  the  metacarpo-phalangeal  joint; — 

When  the  pus  extends  by  way  of  the  synovial  sheath 
it  may  spread  to  the  thenar  space;  either  by  direct  rupture 
into  the  space  or  by  an  intermediate  involvement  that 
embraces  the  lumbrical  space  on  either  side;  less  often 
it  will  involve  the  proximal  interphalangeal  joint  or  come 
to  the  surface. 

Infection  involving  the  thumb,  if  it  spreads  by  the 
fascial  space,  will  readily  come  to  the  surface.     If  by  the 


INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS    195 

synovial  sheath,  it  will  rupture  into  the  forearm  (jr 
possibly  into  the  thenar  space. 

If  the  middle  finger  be  involved  and  the  pus  spreads  by 
the  fascial  space,  it  will  come  to  the  surface  or  lie  in  the 
connective-tissue  space  at  the  web,  whence  it  may  involve 
the  middle  palmar  or  thenar  space  by  way  of  the  lumbrical 
canal.  It  will  generally  come  to  the  surface,  however. 
If  it  spreads  by  way  of  the  tendon  sheath,  it  will  ordinarily 
involve  the  middle  palmar  space  but  may  involve  the 
thenar  space.  In  the  latter  instance,  the  course  is  by  the 
intermediate  channels  along  the  lumbrical  space  between 
the  index  and  middle  fingers.  In  the  former  case  it  is  by 
way  of  the  lumbrical  canal  between  the  middle  and  ring 
finger.  The  proximal  interphalangeal  joint  will  at  times 
become  involved. 

If  the  pus  spreads  along  the  ring  finger  by  way  of  the 
fascial  space,  it  will  be  liable  to  come  to  the  surface  or 
involve  the  connective-tissue  space  on  either  side  of  the 
web,  where  it  will  ordinarily  rupture  externally  but  may 
pass  along  either  lumbrical  canal  into  the  middle  palmar 
space. 

If  the  tendon  sheath  be  involved,  pus  will  invade  the 
middle  palmar  space  either  directly  or  by  rupture  and 
extension  along  the  lumbrical  canal  on  either  side.  It 
may  involve  the  interphalangeal  joint  or  come  to  the 
surface. 

If  infection  spreads  along  the  little  finger  by  w^ay  of 
the  fascial  space,  the  pus  will  either  come  to  the  surface 
or  lie  in  the  connective-tissue  space  of  the  web  between 
the  ring  and  little  finger,  from  whence  it  will  probably 
come  to  the  surface  but  may  spread  along  the  lumbrical 
canal  into  the  middle  palmar  space. 

If  the  pus  spreads  by  the  tendon  sheath  it  will  ordinarily 
extend  into  the  ulnar  bursa  and  from  thence  may  involve 
the  tissue  in  the  forearm  underneath  the  flexor  profundus 
or  rupture  into  the  middle  palmar  space.     It  generally 


196     INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

involves  the  radial  bursa  after  a  clay  or  two.  It  may  be 
confined  in  the  tendon  sheath  of  the  little  finger  and 
rupture  into  the  lumbrical  space  between  the  little  finger 
and  ring  finger  and  thence  involve  the  middle  palmar 
space. 

If  pus  spreads  from  the  palm  and  is  superficial  to  the 
palmar  fascia,  it  will  develop  small  abscesses  which  will 
rupture  quickly.  If  in  the  distal  part  of  the  palm  in  the 
connective  tissue  at  the  web  or  in  the  lumbrical  space,  it 
will  either  come  to  the  surface  at  the  web  or  enter  the 
lumbrical  canal  and  pass  into  either  the  middle  palmar  or 
thenar  space  varying  with  the  area  involved. 

If  in  the  middle  palmar  space,  the  pus  will  extend  into 
the  lumbrical  canals  to  the  web  and  possibly  rupture 
through  the  intervening  tissue  into  the  thenar  space. 

Thenar-space  abscesses  will  ordinarily  come  to  the 
surface  on  the  dorsum,  between  the  thumb  and  index 
finger,  or  may  rupture  into  the  middle  palmar  space. 

If  in  the  hypothenar  space,  the  pus  will  ordinarily  come 
to  the  surface  upon  the  dorsum.  If  underneath  the  skin 
of  the  dorsum,  it  will  readily  rupture  externally;  and  if  in 
the  subaponeurotic  space,  it  will  point  laterally  or  distally 
at  the  edge  of  the  fascial  sheath. 


CHAPTER   XIII. 

PATHOLOGY  OF  TENDON  SHEATH  AND 
FASCIAL-SPACE  ABSCESSES. 

The  discussion  is  here  limited  to  changes  in  the  tendons, 
tendon  sheaths,  and  fascial  spaces.  The  pathology  of 
bone  changes,  arthritis,  and  secondary  sequelae  in  the 
hand  and  forearm  will  be  taken  up  later. 

A  classification  of  the  changes  incident  to  tenosynovitis 
may  be  made  as  follows: 

Primary:  A.  Changes  while  the  infection  is  limited 
to  the  sac:  (i)  Contents  of  sac,  serum,  tendon.  (2) 
Wall  of  sac.     (3)    Circulation,   lymphatics  with  edema. 

B.  When  rupture  of  the  sac  occurs:  (i)  Involvement 
of  the  fascial  spaces,  (a)  hand,  (b)  forearm.  (2)  Involve- 
ment of  the  nerv^es.  (3)  Involvement  of  joints.  (4) 
Involvement  of  bones. 

Secondary:  (i)  Tendon  adhesions.  (2)  Ankylosis  of 
joints.  (3)  Persistent  edema  and  hyperplasia  of  cellular 
tissue;  scar  contraction  with  subsequent  atrophy.  (4) 
Chronic  osteomyelitis. 

The  changes  occurring  in  the  section  under  "primary 
B''  will  be  discussed  under  fascial-space  abscesses  follow- 
ing, and  the  "secondary"  changes  will  be  discussed  in 
detail  in  later  chapters,  dealing  with  the  complications 
and  sequelae  of  infections  (see  Chapter  XXIX). 

THE  TENDON  SHEATH  PROPER. 

Anyone  who  has  had  occasion  to  open  the  acutely 
inflamed  tendon  sheath  has  been  surprised  at  the  rapid 
change  which  has  taken  place.  The  changes  are  com- 
parable to  a  pressure  necrosis,  but  whether  due  to  the 


108     TENDON  SHEATH  AND  FASCIAL  SPACE  ABSCESSES 

great  toxicity  of  the  streptococrus  infection  or  the  threat 
edema  al)oiit  and  the  efifusion  into  the  sheath,  shutting  off 
the  blood  supply,  may  be  a  question. 

The  serum  in  the  sac  in  the  more  acute  cases  is  normally 
scanty  in  amount  and  only  slightly  tinted.  The  con- 
sistency varies  from  a  slightly  slimy  fluid  to  a  thick  pus. 
While  in  the  more  acute  varieties  the  amount  may  at 
times  be  very  great,  it  soon  ruptures,  and  on  operation 
we  may  find  little  or  much  in  the  sac;  in  the  more  chronic 
type  we  frequently  find  a  large  amount  of  thick,  creamy 
pus,  even  though  rupture  has  ensued. 

The  wall  of  the  sac  is  congested  and  edematous  with 
the  exception  of  the  part  under  the  anterior  annular  liga- 
ment where  the  pressure  is  great.  Here  necrosis,  not  alone 
of  the  sheath,  but  also  of  the  tendons  and  even  the  median 
nerve,  is  prone  to  occur.  While  we  may  find  the  synovial 
wall  clear  and  unchanged,  we  generally  find  it  cloudy 
with  whitish-yellow  spots  of  beginning  necrosis,  or  we 
may  find  even  early  the  entire  wall  seminecrotic.  Even 
in  these  cases  we  are  often  surprised  at  the  reparative 
possibilities  after  drainage  is  instituted. 

The  tendons  themselves  are  swollen,  but  retain  their 
glistening  synovial  covering  for  some  time.  At  the  wrist, 
however,  the  tendons  show  the  result  of  compression  by 
the  non-distensible  anterior  annular  ligament,  being  pale 
and  compressed ;  this  is  accentuated  by  the  swelling  which 
has  occurred  both  above  and  below  the  ligament.  If  the 
patient  has  been  left  untreated  for  too  long  a  time,  the 
tendons  lose  their  glossy  covering  and,  becoming  necrotic, 
are  extruded,  looking  like  grayish  strings  of  connective 
tissue. 

While  the  entire  hand  partakes  of  the  edema,  it  is 
in  the  finger  involved  that  the  most  extensive  and  per- 
sistent changes  occur.  Especially  in  the  neglected  cases 
do  we  see  a  most  extensive  exudation  of  inflammatory 
elements  which  persist  for  weeks  after  the  acute  process 
has  subsided ;  this  is  followed  by  an  atrophy  of  the  entire 


rilR  FASCIAL  SPACE  ABSCF.SSFS  199 

finger;  ankylovsis  (^f  joints  and  ini])air(Ml  ncrxc  finuiion, 
which  aids  materially  in  ])re\'enling  a  i)r(jj)er  use  of  the 
finger  even  if  the  tendon  is  not  destroyed.  The  adhesions 
between  the  sheath  and  the  tendon  combined  with  these 
serious  sequelae  make  an  almost  hopeless  prognosis  as  to 
function  in  the  neglected  cases. 

If  the  ulnar  bursa  has  been  involved,  the  ultimate 
result  is  the  characteristic  claw-hand. 

THE  FASCIAL-SPACE  ABSCESSES. 

In  discussing  the  essential  pathology  it  should  be 
remembered  that  we  are  restricting  ourselves  strictly 
to  that  phase  of  the  subject  having  a  relation  to  the 
anatomical  and  experimental  studies  preceding.  The 
pathology  of  acute  abscess  formation  in  connective  tissue 
is  too  well  known  to  merit  discussion  here.-  Moreover, 
to  do  more  than  mention  the  arthritis  in  the  wrist,  the 
osteomyelitis  of  the  metacarpals,  and  the  destruction  of 
tissue  and  fistulous  sequelae  would  be  out  of  place,  since 
these  will  be  discussed  in  the  chapters  dealing  especially 
with  these  subjects.  We  should,  however,  draw  attention 
to  certain  consequences  of  suppuration  in  the  individual 
spaces. 

Let  us  ask  ourselves  what  would  be  the  after-results 
of  infection  of  the  middle  palmar  space  alone,  the  tendon 
sheath  not  being  opened.  We  shall  divide  them  into 
primary  and  secondary;  and  under  the  caption  of  primary, 
attention  should  be  drawn  to  the  fact  that  the  scar  tissue 
following  such  a  process  would  involve  particularly  the 
tendons  of  the  middle  and  ring  fingers,  with  the  lumbrical 
muscles  of  the  middle,  ring,  and  little  fingers.  Conse- 
quentl}^  it  is  in  these  fingers  that  we  would  expect  to  find 
the  most  persistent  adhesions  and  contraction;  and  it  is  in 
consequence  of  the  disturbed  circulation  in  the  blood- 
vessels going  to  these  fingers  that  long  persisting  edema 
and  nutritional  changes  occur,  augmented  somewhat, 
probabl}^  by  impaired  nerve  supply. 


200     TEXDOX  SHEATH  AXD  FASCIAL  SPACE  ABSCESSES 

Secondary  sequelae  eire  noted  in  the  associated  edema 
and  changes  in  the  index  finger  and  the  thumb,  and  while 
these  are  severe,  they  are  not  of  such  high  grade  as  in 
others.  These  changes  are  most  marked  in  the  index 
finger,  and  are  due  to  the  juxtaposition  of  the  tendons  and 
the  intimate  relation  of  the  circulation.  Moreover,  the 
ulnar  bursa,  with  its  contained  tendons,  is  adjacent  to  the 
area  of  infection;  consequently,  there  is  the  probability  of 
a  low  grade  of  inflammation  within.  Again,  the  correla- 
tion of  movement  between  the  tendons  determines 
approximately  the  same  position  for  the  index  finger  as  the 
others.  This  constant  position,  associated  with  an  effu- 
sion into  the  joints,  leads  to  adhesions  of  the  articular 
surfaces  in  all  the  fingers,  the  thumb  least  of  all,  since  the 
tendon  of  the  thumb  is  well  separated  from  the  site  of 
infection.  Should  the  process  extend  to  the  thenar  area, 
the  index  finger  would  then  be  in  the  same  condition  as 
the  other  fingers.  On  the  other  hand,  if  the  infection 
were  primary  in  the  thenar  space,  the  most  disastrous 
changes  would  ensue  in  that  finger,  while  the  other  three 
fingers  would  suffer  only  the  secondary  changes,  but  fortu- 
nately not  so  severe  as  the  secondary  changes  would  be 
in  the  thenar  space  when  associated  with  palmar  infection. 
This  is  owing  not  alone  to  the  comparative  size  and 
complexity  of  the  areas,  but  also  to  the  fact  that  thenar 
abscesses  are  sooner  recognized  and  drained  more  per- 
fectly; consequently  the  process  is  not  so  disastrous. 

Should  the  subaponeurotic  space  be  involved  primarily, 
or  by  an  extension  from  the  palrnar  space,  or  multiple 
ill-advised  incisions  be  made  as  is  too  often  done,  adhesions 
take  place,  and  the  whole  sheet  becomes  more  or  less 
immobile  as  a  consequence  of  the  involvement  of  all  the 
extensor  communis  tendons.  Should  proper  treatment 
be  resorted  to  even  after  a  number  of  days,  all  of  these 
changes  will  disappear  and  a  perfectly  functionating  hand 
be  assured. 


CHAPTER   XIV. 

THE  SYMPTOMS,  SIGNS,  AND  DIAGNOSIS  OF 

TENOSYNOVITIS  AND  FASCIAL-SPACE 

ABSCESSES. 

THE  SYMPTOMS,  SIGNS  AND  DIAGNOSIS  OF  ACUTE 
TENOSYNOVITIS. 

To  diagnosticate  the  onset  of  involvement  of  the 
tendon  sheaths  is  one  of  the  most  difficult  problems 
in  surgery;  and  yet  withal  one  of  the  most  important. 
I  know  of  no  place  where  calm  judgment  is  more  required, 
since  the  symptoms  and  signs  are  all  of  degree.  It  must 
be  said,  however,  that  more  extensive  experience  has 
taught  me  that  it  is  generally  better  to  err  by  making  an 
unnecessary  incision  than  by  failing  to  operate  where  it  is 
needed. 

The  three  cardinal  symptoms  and  signs  are: 

1.  Excessive  tenderness  over  the  course  of  the  sheath, 
limited  to  the  sheath.  This  symptom  is  by  all  odds  the 
most  important. 

2.  Symmetrical  enlargement  of  the  whole  finger. 

3.  Excruciating  pain  on  extending  the  finger,  most 
marked  at  the  proximal  end. 

These  symptoms  are  seen  to  be  only  a  difference  in 
degree  from  those  found  in  any  infection  of  the  hand,  but 
when  sought  for  in  an  intelligent  manner  there  is  not 
much  difficulty  in  differentiating  the  conditions. 

A  patient  applies  to  the  physician  with  what  is  evidently 
a  serious  infection.  If  there  has  been  a  crushing  injury, 
the  probability  of  an  infected  tendon,  sheath  is  great;  on 
the  other  hand,  it  frequently  arises  from  simple  cuts,  as, 
for  instance,  a  slight  laceration  from  a  tin  can  or  from  the 


202     SYMPTOMS,  SIGNS,  DIAGNOSIS  OP  TRNOSYNOVITIS 

prick  ol  a  needle,  or  there  may  he  no  history  of  injury 
The  i)ain  has  increased  in  severity  after  a  day  or  t 
Systemic  symptoms  of  infection  may  be  present, 
finger  and  the  corresj^onding  side  of  the  hand  at  least 
are  edematous.  In  addition  to  the  tumefaction  in  the 
infected  finger  the  adjacent  digits  are  swollen.  The  back 
of  the  hand  particularly  is  edematous.  The  whole  hand 
is  slightly  tender  to  superficial  palpation.  The  fingers 
are  all  slightly  flexed.  Now^how  shall  the  differential 
diagnosis  be  made?  Press  deeply  and  firmly  in  all  parts 
of  the  hand  and  fin|rers;  the  patient  will  volunteer  the 
information  that  all  points  hurt;  but  if  the  tendon  sheath 
is  involved,  pressure  upon  it  throughout  its  course  causes 
an  immediate  and  involuntary  expression  of  pain,  and 
while  before  the  patient  has  allowed  his  hand  to  remain 
passive  in  yours,  he  will  now  attempt  to  withdraw  it 
voluntarily,  and  there  is  no  doubt  in  your  mind  of  the 
exquisite  tenderness  over  this  area.  //  this  tenderness 
is  outlined  by  the  extent  of  the  sheath,  your  diagnosis  is 
nearly  made.  As  a  matter  of  fact,  the  greatest  tenderness 
is  generally  complained  of  on  deep  pressure  at  the  proxi- 
mal end  of  the  finger  sheaths  in  the  palm  of  the  hand,  just 
over  the  metacarpo-phalangeal  articulation.  I  have  seen 
a  lacerated  wound  on  the  back  of  the  finger,  which  was 
inflamed  and  naturally  tender,  show  much  less  sensitive- 
ness than  the  infected  sheath  on  the  opposite  side  of  the 
finger  where  there  was  no  injury.  Now  make  passive 
extension  of  the  finger,  and  the  patient  immediately  com- 
plains of  severe  pain  along  the  tendon  sheath,  very  often 
again  most  marked  at  the  site  of  the  metacarpo-phalangeal 
articulation.  This  is  a  valuable  symptom.  The  flexion 
of  the  fingers  is  of  less  importance  and  is  probably  due  to 
several  factors— the  arthritis  in  the  finger-joints,  possibly 
irritation  of  the  adjacent  filaments  of  the  median  or  ulnar 
nerve,  and  again,  possibly  because  it  lessens  the  tension 
upon  the  tendon.     The  finger  is  generally  held  rigid  in 


ACUTE  TENOSYNOVITIS  20:1 

that  ])()siti()n  and  a  dilTcrcMU-t'  is  readiU-  seen  hclwccii  the 
simple  tiexionoccurrini^  in  llu' adjaccnl  swollen  fmiicrsand 
the  rigid  flexion  of  the  infected  finger.  So  marked  is  this 
that  often  one  is  able  to  diagnosticate  an  extension  into  the 
palmar  sheath,  for  instance,  from  the  little  finger  sheath, 
since  the  character  of  the  flexion  changes  in  that  case  at 
once  in  the  fingers  supplied  by  these  tendons  which  pass 
through  this  common  sheath.  Mauclaire  has  described 
a  claw-hand  position,  but  I  have  not  found  it  to  be 
characteristic  of  acute  inflammation,  but  to  be  rather  the 
evidence  of  an  old  chronic  untreated  tenosynovitis.  The 
entire  finger  shows  a  symmetrical  enlargement.  This  is 
the  essential  diagnostic  point  in  differentiating  tendon 
sheath  infection  from  felons. 

There  are  two  clinical  types  to  be  differentiated: 
First,  that  variety  in  which  the  infection  is  a  local  one, 
generally  of  staphylococcic  origin,  commonly  following 
lacerated  wounds.  Here  we  have  a  local  infection 
beginning  slowly;  plastic  adhesions  may  be  present, 
limiting  the  infection  to  a  particular  part.  There  is  a 
little  general  reaction,  but  the  local  evidences  of  inflam- 
mation are  marked.  A  second  type  is  that  in  which  the 
injury  is  generally  a  slight  one,  a  pin  prick  or  an  insignifi- 
cant cut.  It  is  generally  of  streptococcic  origin.  The  in- 
fection is  carried  to  the  sheath  by  lymphatics.  The  pain 
is  severe,  and  within  a  few  hours  the  finger  is  greatl}- 
swollen,  red,  and  exquisitely  tender.  The  evidences  of 
toxemia  are  present  early,  but  the  red  lines  running 
up  the  arm,  indicative  of  a  lymphangitis,  are  absent, 
although  they  may  have  been  present  early.  (See  Case 
XVIII.)  This  type,  not  having  a  tendency  to  plastic 
adhesions,  spreads  rapidly  throughout  the  entire  com- 
municating^ system  of  sheaths.  This  is  distended  with  a 
fluid,  at  first  only  cloudy,  but  rapidly  becoming  purulent, 
and  on  examination  we  find  thick  pus  with  fragmented 
nuclei,  due  probable  to  the  virulent  toxins,  and  here  and 


204     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

there  streptococci.  This  type  is  prone  to  produce  early 
rupture  and  extension  into  the  connective-tissue  spaces. 
The  spontaneous  pain,  which  was  at  first  severe,  grows 
less  as  the  edema  develops,  and  this  lessening  of  pain 
may  delude  the  surgeon  into  believing  that  the  process  is 
subsiding.  The  arm  seems  to  "fall  asleep,"  as  the  patient 
expresses  it.  Paresthesia,  with  creeping  and  itching 
sensations,  may  be  present,  and  especially  after  rupture 
of  the  sheath  the  tenderness  may  subside  to  a  consider- 
able degree,  leading  the  surgeon  to  an  early  erroneous 
conclusion. 

Symptoms,  Signs  and  Diagnosis  of  Extensions  from  Infections 
Beginning  in  the  Little  Finger. 

An  infection  of  the  sheath  of  the  tendon  in  the  little 
finger  may  be  localized  to  the  finger.  Extensions  to  other 
areas  are  probable,  however  (Fig.  83).  The  following 
are  the  most  common:  (i)  The  ulnar  bursa;  (2)  the 
radial  bursa;  (3)  the  forearm;  (4)  fascial  spaces  in  the 
hand;  (a)  middle  palmar  space;  {b)  lumbrical  space;  (5) 
osseous  involvement,  middle  phalanx;  (6)  joints,  proximal 
interphalangeal,  wrist;  (7)  rupture  to  the  surface. 

Extension  to  the  Ulnar  Bursa. — In  the  fulminating 
type,  where  the  opening  between  the  ulnar  bursa  and  the 
sheath  in  the  little  finger  is  present,  the  infection  extends 
rapidly  throughout  the  hand.  It  should  be  noted  here 
that  the  frequency  of  extension  from  the  one  to  the  other 
is  greater  than  the  anatomical  opening  would  explain; 
we  are  therefore  led  to  conclude  that  the  opening  is  present 
much  more  frequently  than  is  stated,  or  there  is  some  other 
method  of  extension,  possibly  by  the  lymphatics. 

This  extension  is  often  difiicult  to  diagnosticate.  It  is 
marked  by  the  development  of  edema  in  the  hand, 
especially  upon  the  dorsum.  A  general  fulness  in  the 
palm  is  found,  but  the  palmar  concavity  is  still  present. 
On  the  flexor  surface  the  greatest  swelling  is  just  proximal 


rXFECTIONS  BEGINNING  IN   THE  IJTTLE  FINGER    205 

to  the  annular  ligament.  This  is  not  nccessaril)  due  lo 
the  rupture  of  the  sheath  here,  but  to  the  looseness  of  the 
tissues  which  permits  of  distention.  This  swellin.^  is 
accentuated  by  contrast  with  the  non-distensible  annular 


To  epiphyseal  line  and  joint 


I  To  connective-tissue  spac 
'  \    and  around  lumbrical  t 


e  in  web 
muscle. 


^To  surface  through  palmar  fascia. 
To  middle  palmar  space. 


Exceptionally  to  wrist  joint. 


7 — Under  flexor  profundus. 


Fig.  83. — Schematic  drawing,  showing  the  various  probable  extensions  from  an 
infection  of  the  tendon  sheath  of  the  little  finger. 


ligament  distal  to  it.  The  swelling  in  the  palm  occurs 
at  the  same  time,  but  is  not  so  conspicuous,  owing  to  the 
palmar  fascia.  This  also  diffuses  the  swelling  so  that  it  is 
not  accurately  limited  by  the  outline  of  the  ulnar  bursa. 


200     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF    TENOSYNOVITIS 

Moreover,  the  surrounding  edema  tends  to  confuse  the 
picture. 

One  very  seldom  fmds  in  acute  infections  of  the  bursae 
so  great  a  collection  of  pus  within  the  latter  as  to  cause  a 
purely  mechanical  swelling  of  such  extent  that  one  can 
easily  see  it  from  the  outside.  The  wall  of  the  bursa, 
before  an  extensive  formation  of  exudate,  is  necrotic 
and  had  usually  permitted  the  accumulation  to  escape  into 
the  surrounding  connective-tissue  spaces. 


Fig.  84. — Point  of  greatest  tenderness  in  ulnar  bursal  infection. 

The  edema  and  swelling  are  of  such  a  character  that 
fluctuation  can  seldom  be  definitely  elicited.  One  should 
never  wait  for  this  symptom  before  operating.  In  chronic 
tenosynovitis,  such  as  tuberculous  infection,  the  symptom 
is  of  undoubted  value. 

The  most  conspicuous  and  valuable  sign  is  the  extension 
of  the  exquisite  tenderness  to  the  area  involved  and  especially 
at  a  point  just  proximal  to  where  the  distal  flexion  in  the 
palm  crease  joins  the  hypothenar  eminence  (Fig.  84).  It 
should  be  remembered  that  this  is  absent  after  a  few  days. 
The  wrist  becomes  fixed,  the  thumb  shows  tenderness  to 
pressure,  and  particularly  on  i^assive  movement  is  the 
sensitiveness   noted.     It   is   readily   seen   of   how   much 


INFECTIONS  BEGINNING  IN   TIIK  LITTLE  FINGER     207 

importance  this  latter  symptom  is  in  diagnosticating  an 
extension  to  the  ulnar  bursa  from  the  little  finger.  We 
note  that  while  at  first  the  symptoms  are  limited  to  the 
little  finger  and  slight  changes  in  the  ring  finger  because 
of  its  juxtaposition,  all  at  once  the  thumb  begins  to  show 
the  characteristic  signs  of  contracture  and  tenderness, 
while  the  index  and  middle  fingers  remain  unchanged 
except  for  the  increase  of  pain  on  passive  extension 
explained  above.  This  sensitiveness  of  the  thumb  may 
be  due  either  to  the  juxtaposition  of  the  sacs  or  to  a  renal 
extension  into  its  sheath. 

At  first  there  may  be  a  diffuse  redness  of  the  palm  and 
dorsum,  but  it  rapidly  gives  place  to  a  whitish  or  even 
cyanotic  hue.  Above  the  wrist,  however,  the  tissue 
generally  takes  on  a  marked  red  color,  which  later  becomes 
violaceous.  The  temperature  and  pulse  may  not  be  of 
any  diagnostic  importance.  Ordinarily,  after  the  infec- 
tion has  lasted  a  few  days  and  the  walling-off  process  has 
begun,  the  temperature  is  that  of  the  local  accumulation 
of  pus  and  varies  with  the  freedom  of  drainage.  In  the 
first  few  days,  however,  the  systemic  absorption  bears  no 
relation  to  the  abscess  formation  and  cannot  be  relied 
upon  for  diagnostic  purposes. 

Extension  to  the  Radial  Bursa. — ^This  is  diag- 
nosticated as  following  an  ulnar  bursitis  by  the  increased 
swelling  and  tenderness  in  the  thenar  eminence  and  along 
the  sheath  with  the  associated  symptoms  described  above. 
The  tumefaction  of  the  thenar  area  is  not  that  of  abscess 
in  the  thenar  space.  Forssell  states  that  this  extension 
occurred  in  6  out  of  29  cases  coming  under  his  observation 
— average  age,  fifty  to  fifty-eight  years;  23  cases  remained 
confined  to  the  ulnar  bursa — average  age,  thirty-six  to 
thirty-nine  years.  In  my  own  experience  the  percentage 
of  extension  is  far  greater.  I  believe  it  occurs  in  fully  75 
to  85  per  cent,  of  cases.  So  much  has  this  been  impressed 
upon  me  that  in  a  definite  ulnar  bursse  infection  of  forty- 


208    SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

eight  hours' duration  this  extension  should  be  assumed  to 
be  present  and  exploratory  incisions  made. 

Extension  to  the  Forearm. — By  this  we  mean  a 
rupture  from  the  proximal  end  of  the  sheath  and  an 
extension  along  the  connective-tissue  spaces,  or  rather 
the  intermuscular  spaces.  As  I  have  already  pointed 
out,  the  pus  passes  between  the  pronator  quadratus  and 
the  flexor  profundu^^  to  the  area  between  the  latter  and 
the  interosseous  membrane,  and  at  alxjut  the  middle  of 
the  area  it  passes  more  superficially  and  to  the  ulnar  side 
along  the  ulnar  artery  and  nerve.  1  have  had  oppor- 
tunity to  verify  this  area  of  extension  many  times  in  cases 
I  have  operated  upon,  and  have  also  .seen  it  in  one  fatal 
case  I  had  an  opportunity  to  dissect  (Case  XXII).  This 
extension  is  characterized  by  a  brawny  induration  that 
should  not  be  confused  with  the  .softness  of  an  edema. 
No  fluctuation  should  be  expected,  since  the  accumulation 
lies  too  deeply.  This  extension  is  marked  also  by  the  loss 
of  the  relative  swelling  immediately  above  the  annular 
ligament  due  to  the  distended  upper  end  of  the  sheath. 
This  swelling  is  not  any  less,  but  that  of  the  arm  is  greater. 
The  tenderness  may  become  less,  so  it  cannot  be  depended 
upon  as  a  symptom.  The  redness  is  generally  greater, 
and  vspontaneous  pain,  while  at  first  marked,  rapidly 
subsides  (see  Chapter  XXVII).  In  a  definite  ulnar  or 
radial  bursal  infection  that  has  lasted  forty-eight  hours 
such  an  extension  should  be  assumed  and  an  ulnar  fore- 
arm incision  made.  No  harm  will  be  done  if  pus  is  not 
found. 

At  this  time  some  pus  may  accumulate  subcutaneously 
above  the  wrist,  due  to  lymphangitis,  and  lead  to  the 
supposition  that  there  is  no  pus  under  the  tendons,  so 
that  valuable  time  is  lost. 

Extension  to  the  Lumbrical  and  Palmar  Spaces. 
^One  of  the  commonest  sites  of  extension  is  into  the 
lumbrical  and  palmar  spaces.     The  involvement  of  the 


EXTENSIONS  FROM  INFECTIONS  IN   THE  FIXCERS     2()<) 

adjacent  lumbrical  space  occurs  so  freciucntly  as  to  keep 
one  continually  on  his  guard,  since  from  this  involvement 
of  the  tendon  of  the  adjacent  finger  or  palm  may  occur. 
It  is  characterized  by  tenderness,  swelling,  and  pain  at  the 
site.  The  tissue  between  the  fingers  on  the  dorsum  of  the 
corresponding  web  is  generally  swollen  and  red;  the  side 
of  the  adjacent  ring  finger  is  often  red  and  tender.  It 
begins  to  swell  slightly,  and  by  extension  the  tendon  sheath 
of  that  finger  may  exceptionally  become  involved  with 
the  characteristic  symptoms  and  signs.  In  involvement 
of  the  lumbrical  space  alone,  the  swelling  of  the  area 
involved  is  marked.  The  middle  palmar  space  is  in 
neglected  cases  commonly  involved,  either  by  extension 
along  the  lumbrical  space  or  from  rupture  of  the  ulnar 
bursa  directly.  The  thenar  space  is  never  primarily 
involved  in  the  little  finger  infections.  Involvement  of 
the  middle  palmar  space  is  characterized  by  a  slight 
bulging  of  the  palm  replacing  the  normal  concavity.  The 
symptoms  and  signs  of  this  complication,  as  well  as  those 
observed  in  osseous  and  joint  involvement,  will  be  dis- 
cussed in  the  subsequent  pages.  (See  Chapters  XVII 
and  XXIX.)  Mention  should  also  be  made  of  the 
frequency,  in  neglected  cases  of  rupture  of  the  sheath 
through  the  palm  to  the  surface  at  the  proximal  end  of 
the  finger  sheath. 

Symptoms,  Signs  and  Diagnosis  of  Extensions  from  Infections 
Beginning  in  the  Index,  Middle  and  Ring  Fingers. 

Involvement  of  the  index,  middle,  and  ring  fingers 
presents  the  same  signs  as  the  little  finger.  The  only 
difference  is  that  here  the  paths  of  extension  are  dif- 
ferent. The  most  common  extension  is  into  the  lumbrical 
space  on  either  side;  from  here  the  pus  extends  into  either 
the  palm  as  noted  below,  o'r  to  the  dorsum  in  the  web  or  at 
times  to  the  adjacent  tendon  sheath.  (See  Case  VII.) 
The  fingers  differ  somewhat  in  the  method  of  their 
14 


210    SYMPTOMS,  SIGNS,  DIAGXOSIS  OF  TENOSYNOVITIS 


To  epiphyxeal  line 
of  middle  phalanx 
and  joint. 


\    (  To  faxcial  xpaces 
'^SilA     ireh  and  around 


about 
the 
Inmbrical  muscles. 
j,xi~-i^  f  Through  palmar  fascia 
'j\^  (    to  .surface. 

To  thenar  space. 


Fig.  85. — Schematic  drawing,  showing  probable  extensions  from  an  infection  of 
the  tendon  sheath  of  the  index  finger. 


To  epiphyseal  line 
of  middle  phalanx, 
and  to  joint. 


To  fascial  spaces  about 
web  and  around  the 
lumhrical  muscles. 
I  Through  palmar  fascia 
'(    to  surface. 
f  To  middle  palmar  space  ; 
\  exceptionallyj  the  thenar  space. 


Fig.  86. — Schematic  drawing,  showing  probable  extensions  from  infection  of  the 
tendon  sheath  of  the  middle  finger. 


Fig.  87.- 


To  epiphyseal  line 
of  middle  phalanx, 
and  to  joint. 


(  To  fascial  spaces  about 
\    J,     ireb  and  around  the 
'^  {    lumhrical  muscles. 
'-^  (  Through  palmar  fascia 
[    to  surface. 

To  middle  palmar  space. 

-Schematic  drawing,  showing  probalile  extensions  from  the  infection  of 
the  tendon  sheath  of  the  ring  finger. 


EXTENSIONS  FROM  INFECTIONS  IN   THE  FINGERS    211 

extension  into  the  palm,  as  will  be  seen  by  noting  the 
accompanying-  drawings  (Figs.  85,  86,  and  87).  The 
middle  and  ring  fingers  drain  into  the  middle  palmar 
space,  and  the  index  finger  into  the  thenar  space. 

In  common  with  the  little  finger  these  also  present  less 
often  involvement  of  the  middle  phalanx,  the  proximal 
interphalangeal  joint,  and  rupture  to  the  surface  most 
infrequently  of  all. 


Fig.  88. — Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the 
injection  was  made  along  the  tendon  sheath  of  the  index  finger.  Mass  filled 
the  thenar  space  and  extended  along  the  lumbrical  muscle. 

As  illustrating  the  extension  from  the  index  finger 
into  the  thenar  space,  with  no  involvement  of  the  middle 
palmar  space,  I  record  the  case  of  Miss  M.,  seen  with 
Dr.  Besley  at  the  Post-Graduate  Hospital.  The  prob- 
ability of  this  extension  was  pointed  out  by  myself 
experimentally  some  time  previous  to  the  opportunity  to 
observe  a  clinical  case  proving  the  assumption.  Fig.  88 
shows  such  a  condition. 


212    SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

Case  XI. — Seen  in  consultation  with  Dr.  F.  A.  Besiey 
at  the  Post-Graduate  Hospital,  October,  1906. 

History. — Patient  stated  that  twenty-four  hours  before 
she  had  run  a  needle  in  the  distal  phalanx  of  the  index  finger 
of  the  right  hand.  Inside  of  seven  or  eight  hours  the  pain 
became  severe  and  she  arri\ed  at  the  hospital  complaining 
of  excessive  pain  and  tenderness. 

Examination. — Patient's  temperature,  102.5°;  pulse,  100. 
Index  finger  seemed  to  be  slightly  swollen.  Tenderness  was 
present  over  the  entire  finger  and  the  lower  portion  of  the 
hand  on  the  radial  side  without  localization  at  any  point. 
The  glands  in  the  axilla  were  swollen  those  in  the  elbow  not 
involved.     No  lymphatic  lines  seen. 

Treatment. — A  diagnosis  of  lymphatic  infection,  possibly 
tenosynovitis,  was  made  and  hot  boric  dressings  applied. 

The  next  morning  the  temperature  had  fallen  markedly 
and  the  patient  insisted  on  leaving  the  hospital.  She  returned 
in  two  days  with  all  the  evidences  of  acute  systemic  infection 
— temperature,  102°;  headache  and  sleeplessness.  Locally 
the  finger  presented  about  the  same  appearance  as  when  seen 
two  days  before,  except  that  there  was  a  slight  increase  in 
swelling  and  the  thenar  space  from  the  adduction  crease  in 
the  thumb  seemed  to  be  ballooned  out  from  the  remainder 
of  the  hand.    The  concavity  of  the  palm  was  still  present. 

Diagnosis  of  previous  tenosynovitis  in  the  index  tendon 
sheath,  with  rupture  at  its  proximal  end  and  involvement  of 
the  thenar  space  was  made. 

On  operation  pus  was  found  to  be  present ;  there  was  a  very 
large  accumulation  in  the  thenar  space,  which  was  drained 
by  through-and-through  drainage  from  the  palm  to  the 
dorsum  between  the  metacarpal  bones  of  the  index  finger 
and  thumb.  The  tendon  sheath  of  the  index  finger  was  opened 
throughout  its  extent. 

Course. — Patient's  temperature  rapidly  subsided  and  in 
two  or  three  days  was  normal  or  99°.  Infection  of  the  thenar 
space  had  entirely  subsided  at  the  end  of  seven  days,  and  the 
wounds  healed  promptly.  The  opening  in  the  tendon  sheath 
of  the  index  finger,  however,  was  present  for  four  weeks, 
necessitating  repeated  dressings. 

Result. — Recovery  with  all  functions  except  flexion  of  the 
distal  phalanges  of  the  index  finger. 


rXFECTIONS  BEGrXXrXG  rX   THE  RADIAL   BURSA     •_>!:; 


Symptoms,  Signs  and  Diagnosis  ok  ExTiiNsioss  from  Inkection 
Beginning  in  the  Radial  Bursa. 

The  gravity  of  tenosynovitis  of  the  flexor  longus 
poUicis  of  the  thumb  has  long  been  recognized.  The 
symptoms  and  signs  common  to  the  other  fingers  are 
found    here.     To   diagnosticate    the   extension   into    the 


Under  flexor  profundus 


Fig.  89. — Schematic  drawing,  showing  probable  extensions  from  infection  of  the 
tendon  sheath  of  the  thumb.     (Flexor  longus  pollicis.) 

radial  bursa  and  then  to  the  ulnar  bursa  is  more  difficult 
(Fig.  89).  Let  us  suppose  the  thumb  has  been  the  seat 
of  the  primary  infection.  This  member  is  very  painful, 
the  index  fingers  slightly  sensitive,  and  the  other  three 
fingers  hardly  at  all.  After  a  time,  if  the  infection  spreads 
throughout  the  sheath,  all  the  fingers  become  more  painful 
to  passive  extension,  and  should  the  infection  pass  over 
into  the  ulnar  sheath  all  the  fingers  become  flexed  and  the 


214     SYMPTOMS,  STGXS,  DrAGXOSrS  OF  TENOSYXOVTTTS 

])ain  scxcrc  upon  extension  of  the  tendons,  most  marked, 
howexer,  in  the  little  fm^er.  In  other  words,  it  assumes 
the  character  of  an  ulnar  sheath  infection.  The  tender- 
ness over  the  sheath  is  not  always  so  marked  in  secondary 
involvement,  however,  due  possibly  to  the  previously 
developed  edema.  The  diagnosis  is  ordinarily  confirmed 
by  the  presence  of  a  point  of  tenderness  just  proximal  to 
the  point  where  the  distal  flexion  crease  of  the  palm  crosses 
the  ulnar  bursa.  This  area,  about  a  quarter  of  an  inch 
in  diameter  is  nearly  always  distinctly  tender  in  contra- 
distinction to  the  remainder  of  the  palm,  in  fact  it  is 
more  tender  than  is  the  area  over  the  radial  bursa. 
Forssell's  statistics  show  that  23  out  of  2y  cases  of  radial 
bursitis  extended  to  the  ulnar  bursa — average  age  forty- 
three  years;  the  4  that  remained  confined  to  the  radial 
bursa  averaged  thirty-seven  and  one-half  years  of  age. 
In  an  even  larger  series  my  findings  have  been  similar. 
It  cannot  be  emphasized  too  strongly  that  in  the  early 
stage  of  secondary  involvement  of  the  ulnar  bursa  there 
is  no  marked  swelling  upon  the  palmar  surface  and  that 
there  is  no  special  tumefaction  over  the  ulnar  bursa. 

One  fact  may  confuse  the  surgeon  in  that  the  tenderness 
over  the  radial  bursa  may  be  absent.  Not  only  that,  but 
upon  operation  no  macroscopic  pus  may  be  found  in  the 
middle  part  of  the  sheath.  By  careful  extension  of  the 
incision  and  pressure  upon  the  two  ends  pus  may  be 
brought  into  the  wound. 

The  extension  of  the  infection  into  the  radial  bursa  is 
generally  accompanied  by  a  swelling  above  the  anterior 
annular  ligament,  just  as  in  ulnar  bursa  infection.  It 
may  rupture  from  here  into  the  tissues  of  the  forearm, 
and  then  the  pus  lies  under  the  flexor  profundus  tendons 
as  previously  described  in  discussing  rupture  of  the  ulnar 
bursa.  (See  p.  147  and  Chapter  XXVII  for  complete 
discussion  of  forearm  extensions.) 

The  diagnosis  of  involvement  of  the  wrist-joint  will  be 
discussed  in  Chapter  XXVII. 


FASCIALS  PACE  ABSCESSES  2  IT, 

THE  SYMPTOMS,  SI(;NS  AND  DIACiNOSIS  OK  I- ASCIAL-SFACE 

ABSCESSES. 

The  well-defined  spaces  I  have  described  as  being 
present  in  the  hand  may  be  infected  primarily,  or 
secondarily  to  a  tendon-sheath  infection.  In  either  case 
the  symptoms  and  signs  are  the  same  except  that  the 
diagnosis  of  the  location  of  the  pus  is  simplified  when  we 
have  had  a  given  finger  sheath  involved,  as  has  already 
been  pointed  cut.  Let  us  discuss  the  question,  however, 
as  if  we  were  dealing  with  one  or  more  of  the  spaces  with- 
out relation  to  tenosynovitis.  The  student  will  have  no 
difficulty  in  combining  or  differentiating  the  two  pictures 
if  they  are  present  in  an  individual  case,  and  the  dif- 
ferentiation must  be  made,  since  in  draining  a  tendon 
sheath  we  do  not  drain  a  fascial  space,  nor  vice  versa. 
Each  must  be  treated  separately,  even  if  in  a  given  case 
the  two  infections  are  combined. 

The  symptoms  and  signs  may  be  divided  into  local  and 
general.  The  general  evidences  of  this  variety  of  infection 
do  not  differ  at  all  from  those  seen  elsewhere.  The 
temperature  often  reaches  103°  to  104°,  and  the  restless 
tossing  of  the  patient,  the  sleepless  nights,  the  wandering 
eye,  the  sweaty  brow,  and  the  flushed  cheek  all  demon- 
strate the  absorption  of  the  toxins,  bound  in  closed  spaces, 
with  no  means  of  exit. 

Locally,  one  elicits  particular  pain  limited  to  the  area 
involved.  This  localization  of  the  pain  is  not  so  definite, 
however,  as  that  noted  in  the  synovial  sheath  infection, 
particularly  in  those  patients  in  whom  the  mental  equili- 
brium is~  disturbed  as  a  result  of  suffering  and  septic 
intoxication.  After  a  number  of  days  the  tenderness  and 
pain  grow  less  severe,  owing  to  the  edema  with  pressure 
on  the  nerves.  Unfortunately,  the  brawny  induration  so 
helpful  in  diagnosticating  subcutaneous  accumulations  of 
pus  cannot  be  definitely  elicited  upon  the  palmar  surface, 
owing  to  the  palmar  fascia  and  its  general  rigidity.     Upon 


210    SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

the  dorsal  surface,  however,  the  induration  and  localized 
tenderness  will  aid  us  materially  in  distinguishing  between 
•'the  doughy,  pitting  edema  which  is  always  ]:)resent  and  an 
accumulation  of  pus,  long  before  fluctuation  gives  its 
tardy  evidence.  The  position  of  the  fingers  is  worth 
noting.  Incident  to  any  inflammatory  process  about  the 
palm  of  the  hand,  with  its  consequent  edema,  the  fingers 
tend  to  become  flexed;  here,  however,  the  flexion  of  the 
fingers  is  neither  so  marked  nor  so  rigid  as  in  synovial- 
sheath  infection. 

The  Middle  Palmar  and  Thenar  Spaces. 

If  the  middle  palmar  space  be  involved,  we  are  often 
aided  in  making  the  diagnosis  by  the  site  of  the  primary 
injury.  Since  in  the  chapter  upon  Pathogenesis  (Chapter 
XI)  the  routes  of  extension  from  various  fingers  and  parts 
of  the  hand  were  pointed  out,  it  is  not  necessary  to  go  into 
detail  upon  this  subject  again,  although  an  example  may 
be  given.  For  instance,  in  Case  VIII  the  palmar  surface 
was  evidently  involved.  The  fistulous  tract  on  the 
dorsum  opened  over  the  metacarpal  bone  of  the  hypo- 
thenar  area  dorsally;  but  with  the  facts  in  mind  that  the 
metacarpal  bone  of  the  middle  finger  was  fractured  and 
infected,  and  also  that  pus  in  the  subaponeurotic  space 
would  tend  to  point  at  the  side,  a  diagnosis  of  pus  in  the 
middle  palmar  space  rather  than  the  hypothenar  was 
made.  Drainage  of  this  space  was  instituted,  and  the 
immediate  fall  of  the  temperature,  with  rapid  conva- 
lescence, substantiated  the  diagnosis.  Tenderness  most 
marked  over  this  area,  swelling  of  the  whole  hand,  marked 
upon  the  ulnar  side  (or  it  is  better  to  say  without  the 
excessive  swelling  of  the  thenar  area  which  characterizes 
infection  of  that  space),  aid  us  in  making  the  differential 
diagnosis.  The  obliteration  of  the  concavity  of  the 
palm  and  the  presence  of  a  slight  bulging  is  almost 
pathognomonic,    since    while    edema    may    produce    an 


THE  MIDDLE  PALMAR  A.\D   TIILXAR  SPACES      217 

oblileralion  ol  the  ronauily,  I  have  ncxcr  seen  il  pnjdiKc 
a  bulging  or  convexity — a  condition  which  1  have  vseen'ia 
all  large  abscesses  of  the  middle  palmar  space.  Attention 
is  drawn  to  the  relative  swelling  of  the  thenar  and  i)almar 
areas,  since  in  palmar  infections  the  swellings  of  the  two 
might  be  almost  the  same,  owing  to  the  rigidity  of  the 
palmar  fascia  over  the  one  and  its  absence  over  the  other, 
the  swelling  of  the  thenar  space  being  due  to  associated 
edema.  On  the  contrary,  however,  infection  of  the 
thenar  area  is  characterized  by  a  much  greater  swelling 
in  the  thenar  than  the  more  resistant  palmar  tissue;  and, 


Fig.  90. — Photograph  showing  the  ballooning  of  the  thenar  space  when  filled  with 
pus.     Note  that  the  concavity  of  the  palm  still  remains. 


moreover,  the  swelling  of  the  thenar  region  is  greater  than 
that  due  to  the  collateral  edema  of  midpalmar  infection 
(Fig.  90). 

The  position  of  the  fingers  does  not  aid  much,  though 
we  expect  the  middle,  ring,  and  little  fingers  to  be  held  in 
their  characteristic  positions  more  markedly  than  the 
index  when  the  middle  palmar  space  is  involved,  while 
the  converse  is  true  in  thenar-space  involvement.  It  is 
w^ell  to  remember  that  the  fingers  can  be  moved  from  their 
positions  with  much  less  pain  than  is  elicited  when  the 
fingers  are  involved  in  a  tenosynovitis. 


218     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

The  threat  difficult \  in  making  the  dia.unosis,  howcNer, 
is  not  in  those  cases  in  which  the  question  is  onl}  which 
space  is  involved;  it  is  when  we  ask  ourselves,  Are  they 
both  involved?  or  when  we  wish  to  know  whether  a  mid- 
palmar-space  infection  has  spread  over  into  the  thenar 
space,  or  vice  versa.  Fortunately,  how'ever,  the  thenar- 
space  infection  does  have,  to  a  certain  extent,  that  indura- 
tion which  has  been  spoken  of  as  being  absent  in  infections 
under  the  palmar  fascia,  and  this  aids  us,  slightly  at  least, 
to  differentiate  between  collateral  edema  and  pus  in  this 
space.  Moreover,  the  history  helps  us  some.  Given  a 
primary  palmar-space  infection  for  several  days,  we  note 
a  rapid  increase  of  the  size  of  the  thenar  area;  the  edema 
upon  the  dorsum,  w^hich  has  not  been  so  great  as  that 
upon  the  ulnar  side  of  the  hand,  becomes  greater;  the 
palmar  surface  swelling  becomes  very  marked,  the  tissues 
of  the  thenar  area  seeming  to  balloon  out,  as  it  were,  from 
the  adduction  crease  of  the  thumb;  the  thumb  meta- 
carpal is  pushed  away  as  far  as  possible  from  the  hand,  and 
the  flexion  of  the  distal  phalanx  becomes  more  marked, 
although  lacking  the  rigidity  of  synovial  infection  of  the 
flexor  longus  pollicis.  In  such  a  case  we  noW'  fear  an 
extension  into  that  space. 

The  extension  of  an  infection  from  the  thenar  to 
the  palmar  space  is  not  so  common,  fortunately,  since 
diagnosis  is  made  earlier  and  the  proper  treatment 
instituted. 

The  immense  size  to  which  these  infected  hands  may 
grow  can  hardly  be  believed  unless  they  are  seen.  I 
recall  particularly  a  patient  who  presented  himself  with 
such  a  hand  w^hich  had  been  treated  for  four  weeks 
without  the  surgeon  having  diagnosticated  and  opened  a 
typical  middle  palmar  abscess.  It  is  that  of  the  patient 
whose  hands  are  shown  in  Figs.  91  and  92  (Case  XII). 
In  the  photograph  the  two  hands  are  upon  the  same  level, 
and  the  size  of  the  infected  hand  is  not  exaggerated  in  the 


THE  MIDDLE  PALMAR  AM)   TIILXAR  S/'ACLS      I'l!) 

picture.  It  could  lie  c()ini)aiv(l  to  uotliiiiL;  cxci-i)!  the 
appearance  of  a  lar^e  turtle.  The  patient  had  had  ten  to 
fifteen  incisions  upon  the  lingers  and  dorsum  of  the  hand 
when  I  saw  him.  Only  one  incision,  that  of  the  middle 
palmar  space,  was  necessary  for  drainage.  A  cu]:)ful  of 
pus  was  evacuated,  and  the  patient  ultimately  recovered 


Fig.  91. — Photograph  of  dorsum  of  infected  hand.     (See  Case  XII.)     Note 
multiple  ill-advised  incisions  upon  the  dorsum. 

complete  function  of  his  hand,  as  will  be  seen  b}'  examining 
Fig.  93.  He  had  been  advised  by  several  surgeons  to  have 
his  hand  amputated.  There  might  be  some  excuse  for 
the  failure  to  diagnosticate  the  position  of  pus,  since 
the  long-continued  infection  had  so  obtunded  the  nerves 
that  he  complained  of  no  pain  or  tenderness.  This  is 
only  one  of  the  several  patients  that  have  been  seen  some 


220    SYMPTOMS,  SIGXS,   DIAGXOSIS  OF   TEXOSVXOVITIS 

weeks  after  the  l^eginning  (A  the  infection  in  which  the 
diagnosis  as  to  the  position  of  ])us  has  not  been  made, 
and  in  consequence  of  the  apparently  desperate  condition 
of  the  hand  the  advice  to  amputate  had  been  given,  and 


Fig.  92. — Photograph  of  palmar  surface  of  the  same  patient.  Note  wound 
leading  along  lumbrical  muscle  through  which  the  middle  palmar  space  was 
drained.  This  is  the  largest  hand  I  have  ever  seen.  The  pictures  show  the 
right  and  left  hands  respectively  of  the  same  patient.  They  are  on  the  same 
level  and  the  same  distance  from  the  camera.     (Case  XII.; 

yet  upon  proper  drainage  the  patients  secured  serviceable 
hands.     (See  Case  XVI.) 

Case  XII. — Geo.  S.,  Streator,  Illinois.  History  in  Brief. — 
Four  weeks  ago  patient  cut  his  hand  on  a  piece  of  steel.    He 


THE  MIDDLE  PALMAR  AXD   Til  EX  A  R  SPACES      221 

was  in  the  hospital  four  days,  and  it  apparently  recovered. 
Following  this,  numerous  small  pockets  of  pus  developed 
upon  the  hngers,  which  were  opened  by  a  surgeon.  The  hand 
began  to  swell  enormously,  and  incisions  were  made  upon  the 
dorsum  of  the  hand  without  evacuating  much  pus.  The 
patient  began  to  suffer  from  systemic  intoxication. 

Examination  on  Entrance. — General  condition:  tempera- 
ture, 101°;  pulse,  120;  respirations,  26.  Marked  headache 
and  emaciation;  general  evidence  of  systemic  intoxication. 


Fig.  93. — Result  (Case  XII,  Figs.  91  and  92)  six  months  after  treatment.     Note 
perfect  function  of  all  fingers  and  all  joints. 

Locally,  right  hand  swollen  to  two  and  one-half  times  normal 
size.  The  fingers  are  from  one  to  one  and  one-half  inches  in 
diameter.  The  hand  is  at  least  three  inches  thick,  swollen 
both  upon  the  flexor  and  extensor  surfaces.  Forearm  slightly 
swollen.  Numerous  incisions  upon  fingers  and  dorsum,  from 
which  exude  a  moderate  amount  of  pus.  There  is  little  or  no 
tenderness  about  the  hand. 

Upon  the  bulging  of  the  palm  and  the  lack  of  evidences  of 
tendon-sheath  involvement,  a  diagnosis  of  an  abscess  in  the 


222     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOViriS 

middle  palmar  space  was  made.     Incision  along  ring  finger 
lumbrical.    A  cupful  of  pus  was  e\acuated. 

After-history. — Following  the  operation  the  temperature 
rose  to  103°,  and  fell  the  next  day  to  99.8°.  It  rose  to  102° 
the  second  day,  and  then  fell  to  99.4°,  from  which  times  it 
gradually  reached  normal.  The  swelling  slowly  subsided 
under  hot  baths  and  active  and  passive  movements,  so  that 
the  patient  left  the  hospital  at  the  end  of  five  weeks,  with 
three-fourths  function  in  the  hand,  and  at  the  end  of  four 
months,  when  I  had  an  opportunity  to  examine  the  patient, 
the  function  was  perfect  in  every  respect,  as  will  be  seen  by 
examining  the  photographs  (Figs.  91,  92,  and  93. j 

The  Hypothenar  Space. 

Involvement  of  the  hypothenar  space  can  often  be 
prognosticated  from  the  site  of  the  primary  injury,  while 
the  relative  lack  of  swelling  in  the  palm  and  fingers,  with 
absence  of  involvement  of  the  tendons,  combined  with 
ordinar\'  symptoms  of  abscess,  lead  us  to  an  easy  diag- 
nosis. Fortunately,  the  hypothenar  area  is  so  separated 
from  the  remainder  of  the  hand  that  it  is  seldom  if  ever 
involved,  secondarily,  to  palmar  infection. 

Dorsal  Abscesses. 

Attention  is  called  particularly  to  the  rarity  of  abscesses 
upon  the  dorsum.  This  is  necessary  since  the  unthinking 
surgeon  so  commonly  makes  incisions  upon  the  dorsum  in 
patients  having  infections  of  the  hands.  The  excessive 
swelling  due  to  edema  is  mistaken  for  pus.  The  diagnosis 
of  pus  here  is  easily  made  and  no  incision  should  be  made 
except  in  the  presence  of  definite  findings . 

The  excessive  edema  upon  the  dorsum  is  due  to  the 
fact  that  there  we  have  a  large  area  of  loose  subcutaneous 
tissue  in  which  serum  can  accumulate,  and  secondly,  to 
the  anatomical  distribution  of  the  superficial  lymphatics, 
which,  as  we  have  pointed  out,  all  seek  the  shortest  course 


FOREARM  ABSCESSES  22:^ 

from  the  palmar  surface  to  the  dorsum.  Consequently, 
one  often  finds  much  greater  swelling-  upon  the  latter  than 
the  former,  even  though  the  abscess  be  upon  the  palm. 
If,  however,  we  bear  in  mind  the  soft  pitting  of  edema, 
with  its  generalized  moderate  tenderness,  as  opposed  to 
the  induration  with  slight  pitting  and  localized  tenderness 
of  the  abscess  in  this  tissue,  the  diagnosis  is  easy.  One 
should  never  wait  for  fluctuation  to  make  a  diagnosis  of 
abscess  formation;  it  should  be  made  from  the  induration. 
An  infection  localized  under  the  subaponeurotic  fascia 
to  the  exclusion  of  the  subcutaneous  tissue  may  be 
difficult  of  differential  diagnosis.  However,  we  are  aided 
materially  if  we  remember  the  character  of  the  primary 
injury,  the  methods  of  extension  to  this  space  already 
mentioned,  and  the  local  evidences  of  infection  upon  the 
dorsum,  with  the  pitting  edema  of  the  subcutaneous 
tissue,  yet  lacking  the  brawny  induration  and  localized 
tenderness  of  a  subcutaneous  abscess. 

Forearm  Abscesses. 

It  is  w^ell  at  this  time  to  speak  briefly  of  those  cases  in 
which  pus  extends  into  the  forearm.  Personally,  I  have 
not  seen  a  single  case  in  which  an  extension  occurred 
from  an  uncomplicated  mid-palmar  or  thenar-space 
abscess  although  anatomically  it  is  possible.  It  most 
commonly  arises  from  a  radial  or  ulnar  bursitis.  With 
such  an  extension  we  note  the  sudden  increase  of  evidences 
of  inflammation  in  the  forearm;  the  temperature  rises,  the 
tenderness  over  the  forearm  in  front  grows  greater,  and 
the  swelHng, becomes  more  marked;  but  owing  to  the  fact 
that  the  pus  is  deep  under  the  muscles,  induration  is 
absent  until  later,  when  the  whole  area  became  involved, 
and  in  neglected  cases  tends  to  come  to  the  surface 
probably  a  few  inches  above  the  wrist,  along  the  vessels. 


224    SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

(See  Chapters  X  and  XXVII  for  a  full  discussion  of  this 
subject.) 

Osteomyelitis,  arthritis,  and  other  complications  and 
sequelae  have  no  peculiar  relation  to  fascial-space  infection, 
and  hence  will  not  be  considered  in  the  symptoms,  diag- 
nosis, and  treatment.  They  will  be  reserved  for  a  subse- 
quent chapter. 

Differential  Diagnosis. 

One  may  mistake  a  lymphatic  infection  for  a  teno- 
synovitis. Here,  however,  the  red  lines  of  lymphatic 
involvement  running  up  the  arrn  without  localized  tender- 
ness over  the  tendon  sheaths,  the  slight  pain  on  moving 
the  fingers,  the  generalized  edema  of  hand  and  arm  in 
contradistinction  to  the  localized  swelling  found  in  the 
early  stage  of  tenosynovitis  aid  us  in  the  diagnosis. 
Again,  we  may  be  in  doubt  as  to  whether  we  are  dealing 
with  a  tenosynovitis  of  the  ulnar  or  radial  bursa,  or  a 
rheumatism  of  the  wrist.  I  have  seen  several  such  cases. 
In  one  case  it  was  difficult  to  determine  whether  the 
patient  was  suffering  from  a  gonorrheal  rheumatism  of  the 
proximal  interphalangeal  joint  of  a  finger  or  a  gonorrheal 
tenosynovitis  with  secondary  involvement  of  that  joint. 
The  latter  assumption  was  later  found  to  be  the  condition 
present.  In  those  cases  where  there  is  a  lack  of  traumatic 
history  and  an  apparently  spontaneous  development  of 
an  inflammation,  especially  at  the  wrist,  the  diagnosis 
between  arthritis  and  tenosynovitis  may  be  most  difficult 
in  spite  of  the  ease  with  which,  a  theoretical  differential 
diagnosis  is  made.  Here,  again,  however,  the  localized 
tenderness  over  the  sheath  and  pain  on  extension  of  the 
finger  are  of  the  greatest  importance;  moreover,  these 
cases  are  always  virulent  and  extend  rapidly,  so  that  if  it 
be  a  tenosynovitis,  the  hand  grows  rapidly  worse.  In  a 
rheumatism  there  is  as  much  pain  on  the  dorsal  as  on  the 
volar  surface;  the  swelling  involves  the  wrist  more  than 


DIFFERENTIAL  DIAGNOSIS  22 


SJi) 


the  hand,  fingers,  or  forearm;  and  other  joints  may  l)e 
involved.  The  presence  of  a  gonorrhea  does  not  aid  us 
materially,  since  either  condition  may  follow.  Sub- 
cutaneous infections  are  seldom  difficult  to  differentiate. 
One  case  of  gonorrheal  tenosynovitis  of  the  tendon  sheaths 
of  the  dorsum  of  the  wrist  came  under  my  notice  in  which 
the  diagnosis  of  rheumatism  had  been  made.  Here  the 
absence  of  any  tenderness  or  swelling  on  the  flexor  surface 
combined  with  swelling  and  tenderness  localized  to  the 
sheaths  confirmed  the  diagnosis. 

Forssell,  in  a  personal  communication,  has  drawn 
my  attention  to  three  cases  which  came  under  his  observa- 
tion in  which  there  was  a  palmar  infection  represented  by 
necrosis  of  a  part  of  the  palmar  fascia.  This  condition, 
he  states,  was  extremely  difficult  to  diagnosticate  from 
an  ulnar  bursitis.  Personally,  I  have  not  met  with  such 
a  case  and  can  offer  no  suggestion  as  to  its  pathogenesis. 


15 


CHAPTER   XV. 

THE  TREATMENT  OF  ACUTE  SUPPURATIVE 
TENOSYNOVITIS. 

GENERAL  CONSIDERATIONS  AND  REVIEW  OF  THE 
LITERATURE. 

Before  discussing  my  own  views  as  to  the  site  and 
course  of  the  incisions  for  the  various  fingers  when  the 
diagnosis  of  tenosynovitis  has  been  made,  let  us  study  the 
suggestions  of  those  who  have  previously  made  contribu- 
tions to  this  subject. 

Professor  Bier  (Berlin),  with  his  assistants,  has  been  an 
active  advocate  of  the  production  of  passive  hyperemia 
in  these  cases  of  infection  of  the  hand.  His  method 
consists  in  applying  a  constrictor  to  the  arm  so  as  to 
produce  a  moderate  passive  hyperemia  without  causing 
pain  and  without  restricting  the  arterial  flow  of  blood. 
The  constrictor  should  be  a  broad  band,  and  to  prevent 
pain  should  extend  from  two  to  four  inches  up  and  down 
the  arm.  It  should  be  so  applied  that  the  full  amount  of 
edema  does  not  appear  at  once,  but  accumulates  gradually 
for  from  three  to  four  hours.  The  constrictor  is  left  on 
from  sixteen  to  twenty-four  hours.  After  an  interval 
of  from  two  to  four  hours  it  is  reapplied.  Small  incisions 
are  made  into  the  tendon  sheaths  or  other  sites  of  pus. 

Klapp  has  added  to  this  by  suggesting  the  use  of  suction 
cups,  these  being  applied  so  as  to  produce  moderate 
hyperemia  without  pain.  Cups  from  which  the  air  can 
be  exhausted  are  used  over  localized  accumulations  of  pus. 
Long  glasses  with  rubbers  at  the  end,  which  can  be  applied 
over  the  finger,  as  shown  by  the  illustrations,  have  also 
been  devised. 


EXCERPTS  FROM  THE  LITERATURE  227 

In  involvement  of  the  connective-tissue  .spaces,  it  is 
my  personal  opinion  that  these  appliances  may  l)e  of 
slight  value.  In  other  conditions  the  benefit  to  be  derived 
it  would  seem,  is  so  slight  as  hardly  to  justify  their  use. 
Many  German  surgeons  have  maintained  that  Bier's 
methods  are  of  value  in  tendon-sheath  infections,  but 
personally  I  have  never  been  able  to  secure  good  results 
with  them,  except  possibly  in  a  few  cases  where  there  has 
been,  a  sinus,  leading  down  to  a  tendon  sheath.  The 
sinus  seemed  to  close  more  rapidly  under  the  suction  cup 
of  Klapp  than  by  other  means. 

In  order  to  prevent  rapid  absorption  of  toxins,  it  is  my 
habit,  after  operation  upon  exceptionally  virulent  cases, 
to  leave  on  an  Esmarch  constrictor  for  from  twelve  to 
twenty-four  hours  after  operation,  except  that  a  con- 
strictor is  loosened  to  produce  only  a  slight  hyperemia. 

I  cannot  but  feel  that  while  slight  benefit  may  occur 
in  some  cases,  the  so-called  Bier  treatment  of  infections 
of  the  hand  cannot  be  looked  upon  as  a  marked  aid. 

Excerpts  from  the  Liter.\ture. 

Klapp  and  other  surgeons  have  discussed  the.  Bier 
method  of  treatment  in  these  cases  at  the  German  Surgical 
Congress.^ 

Klapp  now  makes  free  incisions  in  the  tendon  sheaths  at 
the  lateral  surface  of  the  fingers  and  cuts  the  ulnar  bursa 
throughout  its  length  with  the  exception  of  the  anterior 
annular  ligament,  using  alcohol  dressings,  and  active  move- 
ments the  first  day.  His  results  have  apparently  been  as 
satisfactory  as  those  obtained  by  Bier  and  Klapp  previously 
where  they  made  small  incisions  into  the  tendon  sheaths  and 
applied  the  Bier  constrictor.  By  this  method  he  had  treated 
19  cases. 

1  Berl.  klin.  Wchnschr.,  April  13,  1908,  No.  25. 


228    TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

1.  Ten  cases  of  pure  tendon-sheath  infection:  9  healed 
with  necrosis. 

2.  Two  cases  of  subcutaneous  abscess  under  the  tendon 
with  necrosis  of  the  skin:  i  healed  and  i  recovered  completely. 

3.  Six  cases  of  tendon-sheath  infection  complicated  with 
infected  phalangeal  fractures:  2  of  these  healed,  and  4  became 
necrotic. 

4.  One  case  developed  sepsis  and  died  on  the  twelfth  day. 

Klapp  therefore  concludes  that  he  has  thus  answered 
the  question  as  to  whether  Bier's  good  results  came  from 
hyperemia  or  from  the  physiological  treatment.  He 
maintains  that  he  has  proved  that  it  came  from  the 
latter.  He  now  proposes  to  study  whether  good  opening, 
physiological  treatment,  and  Bier's  hyperemia  wull  not 
produce  still  better  results. 

Klapp's  paper  was  discussed  by  Joseph,  who  suggested 
that  there  are  two  types  of  the  infection  which  must  be 
dilTerentiated:  (i)  a  type  in  which  it  is  localized  to  the 
sheath,  not  show'ing  a  tendency  to  spread;  (2)  a  type 
which  shows  a  tendency  to  spread  beyond,  due  to  the  great 
virulence  of  the  infection. 

He  maintained  that  we  should  use  care  not  to  go  beyond 
the  zone  of  protection  which  Nature  has  thrown  out  to 
wall  off  the  infection,  whether  it  be  within  the  sheath  or 
without.  In  these  cases  we  should  use  the  smallest 
possible  incisions  and  Bier's  hyperemia. 

Kausch  stated  that  he  had  treated  a  large  number  of 
tendon-sheath  infections  after  Bier's  method,  and  must 
say  he  was  generally  well  satisfied  with  the  result.  He  has 
not  been  vSO  well  satisfied  with  the  very  severe  cases.  In 
the  beginning  he  used  small  incisions,  then  medium-sized, 
and  drained  with  passive  hyperemia,  but  in  his  severe 
cases  he  has  now  gone  back  to  large  incisions,  although 
not  as  large  as  formerly. 

Karewski  stated  that  he  could  not  attribute  his  bad 


EXCERPTS  FROM   THE   UTERATIRE  220 

results  lo  llu'  BicM"  method,  l)ii(  rather  lo  Ihe  laet  (liat  his 
material  was  ambulatory  and  could  not  be  correctly 
handled.  He  had  used  the  older  method  for  twenty-five 
years.  He  now  makes  ii  moderate-sized  incision,  packs 
lightly,  and  keeps  the  arm  at  rest  as  long  as  there  is  fever. 
Of  57  cases,  4  had  to  have  amputation  of  the  fingers  at 
once.  Of  the  53  cases  remaining,  9  w^ere  treated  by  lateral 
incisions.  Of  the  53  cases,  42  showed  good  results:  that 
is,  79.25  per  cent.;  bad  results,  5  cases,  or  9.5  per  cent. 
This  result  is  better  than  that  given  by  Dr.  Klapp. 

Forssell,  in  his  monograph  previously  referred  to,  has 
collected  the  opinions  of  various  surgeons,  and  I  shall 
quote  and  abstract  extensively  from  him.  He  gives  the 
results  of  his  own  experience  as  follows.^ 

"Even  if  one  makes  smaller  incisions  into  the  sheath,  at 
least  according  to  the  experience  met  with  in  the  Seraphimer- 
Lazarett,  one  rarely  succeeds  in  saving  the  sheath  (Poulsen's 
experience  was  the  opposite).  I  have  often  attempted  to 
treat  such  an  infection  with  incision  at  each  end  of  the  tendon 
sheath  and  with  complete  exposure  of  the  surrounding  folds 
of  the  synovialis  (and  subsequent  washing  of  the  sheath  with 
water,  normal  salt  solution,  boric  acid  solution,  iodoform- 
glycerin,  weak  carbolic  or  sublimate  solutions),  but  only  on 
three  occasions  was  this  treatment  successful. 

"The  treatment  which  in  my  judgment  should  be  used  in 
most  cases  is  a  complete  splitting  of  the  sheath  from  one  end 
to  the  other.  Thus,  one  often  succeeds  in  saving  at  least  the 
inner  tendon  from  complete  necrosis. 

"For  the  opening  of  the  ulnar  sheath  on  the  forearm,  if  for 
some  reason  one  prefers  to  begin  the  incision  here,  several 
starting-points  are  at  his  command.  If  one  can  determine 
the  ulnar  pulse,  the  skin  incision  is  made  i  cm.  to  the  radial 
side  thereof,  and  after  cutting  through  the  fascia  meets  the 
collected  muscular  bundle  of  flexors  of  the  fingers,  at  whose 
ulnar  a;nd  posterior  circumference  the  sheath  extends  farthest 
upward ;  by  passive  movement  of  the  ulnar  finger  it  is  now  a 

1  Nord.  med.  Ark.,  1903,  Abt.  i,  Heft.  3. 


2:;(  I     TRE.  I  7M/A'.V T  OF  SUPPURA  Tf  I 'E  TEXOSy.XOVmS 

simple  matter  to  know  the  lay  of  the  land,  if  one  does  not 
feel  the  ulnar  pulse,  nor  the  os  pisiforme,  which  lies  close  to 
the  ulnar  side  of  the  ulnar  artery,  nor  the  uncif(jrm,  on  whose 
radial  boundary  the  incision  must  fall,  one  can  make  the  skin 
incision  on  the  border  of  the  middle  and  inner  third  of  the 
wTist-joint  and  then  dissect  layer  for  layer  down  to  the  tendon 
sheath. 

"If  it  is  a  case  of  inflammation  of  the  ulnar  sheath  of  the 
palm  and  the  tendon  sheath  of  the  little  finger,  it  is  often 
preferable  to  begin  with  the  incision  of  the  latter.  Only  in 
exceptional  cases  it  might  be  worth  while  to  use  a  more  con- 
servative treatment,  and  that  especially  in  such  cases  of 
fresh  tenovaginitis,  where  this  is  secondary,  after  an  ulnar 
bursitis;  in  such  cases  one  can  occasionally  make  an  attempt 
to  conquer  the  inflammatory  process  by  w^ashing  out  the 
tendon  sheath  through  incisions  rhade  in  either  end;  there  is 
little  danger  in  this  method,  and  if  successful,  it  insures  com- 
plete movability  of  the  little  finger. 

"The  skin  incision  must  then  be  laid  from  the  upper  end 
of  the  opened  little  finger  sheath,  up  toward  the  hook  of  the 
unciform  (i.  e.,  must  follow  the  radial  boundary  of  the  hypo- 
thenar  eminence),  and  then  continued  in  the  length  of  the 
forearm  to  a  point  3  or  4  cm.  or  more  above  the  wrist.  After 
cutting  through  the  skin  and  the  subcutaneous  fat,  usually 
especially  developed  here,  the  palmar  aponeurosis,  the  strong 
anterior  annular  ligament,  and  the  forearm  fascia  are  cleft, 
the  superficial  vessels  cut  through  and  ligated  (the  ligatures 
being  left  long  because  the  vessels  usually  draw  back  deep 
into  the  tissue  and  with  their  infected  ligatures  give  rise  to 
collections  of  pus  which  might  easily  be  overlooked),  after 
which  the  sheath  is  opened.  Even  when  the  infection  is 
confined  to  the  tendon  sheath,  the  incision  should  be  con- 
tinued in  the  skin  and  soft  parts  until  it  gives  a  good  opening 
into  the  sheath,  through  which  this  can  be  easily  and  com- 
pletely packed  with  gauze. 

"In  continuing  the  incision,  it  must  not  be  allowed  to 
deviate  too  far  to  the  ulnar  side,  as  the  ulnar  nerve  and  artery 
might  thus  be  injured;  the  cut  can  and  should  be  so  laid  that 
neither  of  them  is  exposed.  The  anterior  annular  ligament  is 
best  cut  some  distance  from  the  hook  of  the  unciform. 

"If,  however,  it  is  a  question  of  suppuration  of  the  radial 
bursa,  I  believe  that  a  complete  cutting  of  the  anterior  wall 


EXCERPTS  FROM   THE  LITERATURE  'l:\\ 

of  the  bursa  should  not  be  attempted.  If  the  hicision  is  made 
in  the  early  stages  of  the  infection,  one  may  have  the  satis- 
faction of  seeing  the  tendon  of  the  thumb  saved  and  the  infec- 
tion restricted;  the  tendon  cannot,  however,  be  saved  in  all 
these  cases,  and  sometimes,  moreover,  it  is  rendered  useless 
by  adhesions  to  neighboring  regions.  An  incision  of  the  whole 
length  of  the  sheath  is  to  be  regarded  as  even  more  than  useless 
when  it  is  attempted  in  more  advanced  cases  where  there  is 
no  chance  of  saving  the  tendon  since  the  suppuration  is  kept 
up  by  the  necrotic  tendon;  moreover,  such  an  operation  lames 
an  important  group  of  muscles  and  so  makes  the  thumb 
practically  useless. 

"How,  then,  should  one  proceed  in  suppurations  of  this 
order .■^     I  believe  there  are  three  ways  at  our  command; 

'*  I.  Incision  in  the  radial  bursa  above  and  below  the  liga- 
mentum  carpi,  sparing  the  nerve  of  the  thenar  group.  The 
first  mention  of  this  method  which  I  have  found  in  the  litera- 
ture I  found  in  an  article  by  Nicaise  [Gazette  medicate  de  Paris, 
1870.  p.  615).  who,  however,  opens  only  the  tendon  sheath 
of  the  thumb  under  the  carpal  ligament  and  not  the  radial 
bursa;  the  case  ended  in  necrosis  of  the  distal  part  of  the 
tendon.  Surely,  then,  if  a  decided  improvement  has  not  been 
shown  within  the  first  twenty-four  hours,  one  should  proceed 
more  radically,  in  which  case  the  choice  is  between  the  two 
following  methods; 

"2.  Incision  as  in  i,  and  excision  of  the  long  flexor  tendon 
of  the  thumb.  Through  removal  of  the  tendon,  which  is 
usually  the  principal  reason  for  persistent  suppuration,  one 
also  gains  a  lessened  pressure  in  the  radial  bursa  and  better 
drainage  with  less  danger  of  a  spreading  of  the  inflammation. 
Primary-  excision  of  the  tendon  is  to  be  considered ;  ( i )  When 
the  tendon  is  already  necrotic  or  its  continuity  broken,  or 
if  it  is  so  injured  that  its  restitution  seems  hopeless;  (2)  if 
the  s>Tioyialis  is  infiltrated  with  pus  and  is  necrotic;  (3)  in 
case  of  inflammation  of  the  joint  or  fracture  of  the  thumb 
whereby  the  functions  of  either  the  interphalangeal  joint  or 
of  tendon  are  completely  interrupted;  (4)  in  people  of  age  or 
poor  general  condition. 

"3.  A  more  or  less  complete  cutting  of  the  ligamentum 
carpi  beginning  at  the  upper  edge  is  added  to  the  above- 
mentioned  incision.  Complete  fissure  of  the  ligamentum 
carpi  can  be  carried  out  without  any  direct  injury  to  the 


232    TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

motor  nicdiaiiiis  branch  to  tlu-  (lu'iiar  nuisclcs;  ui'\ crthclcss, 
this  ncTNc  l)ranch  in  case  of  an  infection  ot  the  I'dges  of  the 
wound  niiglit  possibly  be  exposed  to  the  dangers  of  necrosis." 

I  am  in  receipt  of  a  letter  from  Dr.  Forssell,  under 
date  of  September  lo,  1908,  in  which  he  reiterates  his 
belief  in  free  incision.     It  is  abbreviated  as  follows: 

"With  regard  to  your  query,  whether  I  have  modified  my 
opinion  of  the  complete  splitting  of  the  tendon  sheath  from 
the  end  of  the  finger  up  into  the  forearm,  I  must  answer  that 
I  still  adhere  to  it  with  the  exception  mentioned  on  pages  37 
and  63  of  my  paper,  i.  e.,  I  still  make  attempts  sometimes 
w4th  smaller  incisions  and  irrigations  through  the  tendon 
sheaths  of  the  thumb  and  little  finger  when  a  tendon  sheath 
has  there  given  rise  to  an  infection  of  the  radial  or  ulnar 
bursa  and  split  the  tendon  sheath  of  the  finger  only  when  the 
smaller  incisions  do  not  lead  to  the  desired  results. 

"Prof.  Bier's  hyperemic  treatment  has  been  used  by  me 
for  a  few  cases  of  infection,  but  without  any  appreciable 
benefit,  this  being  also  my  experience  with  cases  of  tendon- 
sheath  infection.  The  material  at  my  disposal  may,  however, 
have  been  too  slight  for  my  forming  an  opinion  of  my  own 
concerning  the  value  of  the  Bier  method  for  tendon-sheath 
infections.  At  the  surgical  department  of  the  Karolinska 
Institute  (The  Royal  Seraphim  Hospital),  where  I  w^orked 
out  my  paper,  and  where  the  principles  I  advocated  gained 
general  approbation,  and  caused  a  considerable  improvement 
in  the  results  obtained,  there  was  later  on  a  good  deal  of 
enthusiasm  felt  for  the  method  invented  by  Bier;  but  I  was 
told  that  some  time  ago  the  method  was  discontinued,  since 
it  had  given  several  very  unfavorable  running  cases,  and  in 
the  main  the  former  old  method  of  treatment  has  been  taken 
up  again. 

"Whatever  method  may  be  used,  I  feel  sure  that  fatal 
cases  will  have  to  be  deplored.  As  the  prophylaxis,  there- 
fore, is  invariably  of  the  very  greatest  importance,  I  have 
lately  come  to  the  conclusion  that  one  way  of  trying  to  pre- 
vent infections  of  the  fingers  from  attacking  the  tendon 
sheaths  is  by  previously  exposing  the  tendon  and  tamponing 
it  around,  to  the  extent  of  a  couple  of  centimeters.  This 
proceeding  should  be  of  special  use  in  necrosis  of  the  end 


EXCERPTS  FROM   THE  LITKRATrRR  233 

pluilanx  ol  ihr  thiuiil)  lluil  so  ottcn  occurs  and  which  greatly 
eiichuiiicrs  the  tt-ndoii  shoatli  of  the  ihunil*  and  thus  also  the 
bursa  of  the  hand. 

"The  method  has  been  i)roved  l)y  nie  as  yet  in  l)ut  one 
single  case,  though  with  success.  I  then  proceeded  as  follows: 
The  tendon  sheath  of  the  thumb  was  split  to  the  extent  of  a 
couple  of  centimeters,  the  tendon  was  cut  near  its  attachment 
on  the  end  phalanx,  and  was  flexed  by  a  suture  in  the  \icinity 
to  its  surroundings,  a  tampon  being  placed  around  it.  After 
this  the  necrotic  phalanx  with  the  tendon  attachments  was 
removed. 

"Seeing  the  interest  you  have  for  the  infections  of  the  hand 
in  general,  I  must  call  your  attention  to  the  small  contribu- 
tion I  have  given  in  pages  32  and  33  of  my  paper.  So  far  as 
I  am  aware,  the  isolated  necrosis  of  the  fascia  palmaris  has 
not  previously  been  mentioned  in  literature,  which  is  singular, 
since  both  from  a  diagnostic  and  therapeutic  point  of  view  it 
is  of  great  interest.  I  have  recently  had  a  similar  case  under 
treatment.  An  English  sailor  a  fortnight  previous  to  being 
admitted  to  the  hospital  had  punctured  his  hand  with  a  nail. 
Besides  the  mark  of  the  injury,  there  was  great  soreness  in 
the  palm,  accompanied  by  considerable  swelling  of  both  palm 
and  back  of  the  hand,  with  a  very  obser\'able  crooking  of  the 
lingers,  together  with  pain  when  moved  but  no  tenderness 
when  the  fingers  themselves  were  subjected  to  palpation. 
The  diagnosis  was  made  of  a  probable  abscess  in  or  around 
one  of  the  aforesaid  fascia,  which  Avas  found  to  be  necrotic  in 
the  great  part  of  its  extent,  this  without  any  appreciable 
accumulation  of  pus  in  the  vicinity.  It  would  be  interesting  to 
hear  whether  you  ha\'e  had  any  occasion  of  observing  a  case 
of  this  localizing  of  the  infection." 

It  may  be  of  interest  to  note  some  of  the  earlier  opinions 
concerning  the  treatment  of  these  cases. 

\V.  Heineke,  in  his  Ajiatomie  iiud  Patliologie  der  Schleim- 
heiUel  nnd  Seh?ienscheiden,  Erlangen,  1869,  p.  79,  speaks 
of  the  acute  inflammations  of  the  tendon  sheaths  of  the 
hand: 

"The  only  cure  in  these  malignant  inflammations  is  to  be 
found  in  an  earlv  and  extensive  incision;  thus,  one  can  some- 


2:54     TRK.  I  TME\' T  OF  S[  PPL  R.  1  77 1 ' E    PESOS  1  'SO  1  'ITIH 

times  prevent  a  necrosis  of  the  tendon,  l)Ut  one  must  not 
expect  too  much  in  this  direction.  After  cutting  several 
openings,  one  can,  by  use  of  the  drain,  help  the  outflow  of 
pus  and  the  cleaning  of  the  wound." 

An  article  by  Scheide^  shows  what  a  lack  of  even 
elemental  knowledge  there  has  been  in  the  past  in  regard 
to  the  position  of  the  pus  in  these  cases.  He  warns 
against  hot  cataplasm  treatment  by  these  diseases  and 
recommends  that  introduced  by  von  \'olkmann,  the  so- 
called  vertical  suspension  of  the  arm  together  with  con- 
tinuous ice  applications,  and  even  painting  with  iodine. 

"In  very  great  swellings,  and  excessive  overfilling  of  the 
\'eins,  numerous  stabs  with  a  very  sharp  knife  often  do  good 
service.  When  the  period  of  progressive  inflammation  has 
passed  and  with  it  the  danger  of  death,  when  the  healing  has 
begun,  then  the  question  will  again  be,  What  operations  are 
necessary?  Many  a  necrotic  phalanx,  many  a  finger  whose 
tendon  sheath  has  become  purulent,  will  have  to  be  removed ; 
and  now  another  question  becomes  of  primary  importance, 
the  greatest  possible  functional  activity  of  the  remaining 
parts. 

"This  latter  is  most  frequently  hindered  through  the  neces- 
sary fixation  of  the  hand  for  weeks  and  months,  thus  causing 
the  fingers  to  lose  a  great  part  of  their  power  of  motion.  The 
well-known  changes  to  which  joints  are  subject  when  kept 
stiff  for  a  long  while  seem  to  take  place  especially  quickly  in 
these  small  joints  under  the  influence  of  rest  and  the  inflamma- 
tion of  the  surrounding  tissue.  One  distinctly  feels  then  how 
in  bending  pseudoligaments  snap  or  the  capsule  tears.  With 
the  necessary  patience  and  endurance  one  can  master  these 
disturbances  without  a  doubt.  But  a  great  deal  of  trouble 
to  the  physician  and  pain  to  the  patient  would  be  avoided  if 
immediately  after  the  first  period  of  reaction  simple  passive 
exercises  were  given  whenever  the  dressing  was  changed  and 
so  prevent  any  severe  stiffening  of  the  joint." 

■  Ueber  Hand  und  Fingerverletzungen,  Volkmann's  Sammlung  klinischer 
Vortriige,  1871,  \o.  29,  Note  1. 


EXCERPTS  FROyr   TTIF.   UTERATrRE  23.") 

Schiik'r'  shows  ihu  sanu'  lack  of  aiKitomlcal  knowledge. 
His  remarks  are  t>pical  in  that  they  show  a  lack  of 
tendency  to  make  an  early  diagnosis.  His  drainage  under 
the  anterior  annular  ligament  should  also  be  condemned. 
The  same  may  be  said  concerning  the  remarks  of  Tillaux, 
which  follow: 

"If  after  a  tendonal  panaritium  of  the  thumb  a  doughy 
swelling  along  the  arterioradialis  of  the  forearm  is  noticeable, 
pressure  there  and  on  either  side  of  the  ligamentum  carpi 
volare  is  very  painful,  while  the  fingers  are  crooked,  it  is 
advisable  to  make  a  few  incisions  immediately,  if  possible, 
along  the  line  of  the  flexor  longus  polUcis,  into  the  tendon 
sheath  as  far  as  the  muscle,  in  order  to  prevent  further  changes 
especially  the  occurrence  of  pyemia  or  septicemia.  The 
incisions  are  made  to  the  best  advantage  on  the  forearm 
outward  (radially)  from  the  arterioradialis  and  along  it.  In 
some  cases  this  is  sufficient,  as  evidently  the  whole  of  the 
great  tendon  sheath  is  not  alwa^^s  affected  from  the  very 
beginning,  but  only  its  radial  half.  In  other  cases,  further 
incisions  in  the  great  tendon  sheath,  in  the  ulnar  side,  are 
necessary.  Here  an  incision  is  made  to  the  best  advantage 
close  above  the  anterior  annular  ligament  and  at  that,  not 
exactly  in  the  center,  but  to  avoid  injuring  the  median,  more 
toward  the  ulnar  side  and  in  the  direction  of  the  long  axis 
of  the  forearm.  That  one  should  put  drains  in  all  incisions 
(best  under  the  ligamentum  carpi  volare),  wash  out  the 
pockets  with  an  antiseptic  fluid,  and  bandage  the  wound 
antiseptically,  I  will  only  mention  in  passing.  Sometimes 
even  these  incisions  are  not  sufficient;  then  one  must  add 
similar  ones  in  the  palm  and  in  the  forearm." 

P.    Tillaux-    speaks    of    the    so-called    subaponeurotic 
abscess : 

"One  must  hasten  to  make  two  incisions,  one  in  the  palm 
of  the  hand,  the  other  in  the  forearm,  connecting  them  by  a 

1  Chirurgische-Anatomische    Studien    iiber    die    Sehnenscheiden    der    Hand, 
deutsche  med.  Wchnschr.,  1878. 

-  Traite  d'anatomie  topographique,  1887,  p.  572. 


■2:](\     TREATMEXT  OF  SUPPURATIVE  TEXOSYXOVITIS 

drainage  tul^c  which  passes  behind  the  anterior  annular  liga- 
ment of  the  wrist." 

Concerning  operation  when  a  diagnosis  of  extension 
into  the  forearm  is  made,  he  continues  as  follows:^ 

"It  is  now  well  to  delay  no  longer  in  opening  the  focus 
extensively  without  waiting  for  the  fluctuation  to  become 
more  superficial.  In  reaching  the  skin  the  pus  must  invade 
the  lower  layers  of  the  forearm  and  also  the  radio-carpal 
articulation. 

"In  making  this  opening  one  must  cut  through  the  entire 
thickness  of  the  antibrachial  region  and  '  manage '  the  import- 
ant organs  there  enclosed,  especially  the  median  nerve. 
Remember  that  this  ner\'e  is  placed  slightly  without  the  axis 
of  the  forearm ;  consequently  the  place  to  choose  for  the  open- 
ing of  deep  abscesses  of  the  wrist-joint  is  located  just  inside 
the  median  line. 

"At  this  level  make  an  incision  about  4  to  5  cm.  long,  and 
successively,  layer  for  layer,  as  if  for  a  ligature  of  the  artery, 
cut  through  all  the  soft  parts  of  the  forearm  until  you  reach 
the  focus. 

"If  in  the  hand  there  be  a  focus  communicating  with  that 
of  the  wrist  below  the  anterior  annular  ligament  of  the  wrist, 
it  would  be  necessary  to  drain  it,  and  it  might  be  even  neces- 
sary to  make  another  opening." 

Farther  on  (pages  684  and  685)  he  not  only  continues 
to  show  a  lack  of  knowledge  of  the  anatomical  and 
pathological  condition  present,  but  advises  procedures 
which  should  be  condemned. 

"Subaponeurotic  abscess.  The  abscess  must  be  opened 
from  the  palmar  surface,  always  remembering  that  the  super- 
ficial palmar  arch  lies  in  a  transverse  line,  beginning  at  the 
root  of  the  thumb.  One  should,  at  the  same  time,  open  the 
abscess  from  the  dorsal  side  and  establish  thorough  drainage. 

"If  necessary,   pass  another  drain,  joining  the  hand  and 

'  Traite  de  chir.  clinique,  1897,  vol.  i,  p.  674. 


EXCERPTS  FROM   THE  UTERATLRE  2'M 

wrist   through   the   radiocarpal   canal.      Long  carbolic   bath 
should  be  given." 

Konig^  speaks  for  early  and  large  incisions,  strong 
antiseptics  (5  per  cent,  carbolic  acid),  drainage,  suitable 
position  of  the  hand  and  finger  inside  the  bandage,  vertical 
suspension  of  the  arm,  excision  of  the  arm,  excision  of  the 
necrotic  tendon,  but  only  after  a  true  loosening  has  taken 
place. 

"But  even  when  the  tenovaginitis  has  persisted  for  a  long 
time,  if  the  abscesses  have  formed  along  the  forearm  with 
suppuration,  much  may  be  accomplished  with  antiseptic 
treatment.  Here.  too.  it  is  a  question,  after  one  or  two  days 
of  suspension,  to  stop  the  swelling,  of  extensive  opening  of  the 
abscesses  and  drainage,  to  introduce  a  number  of  small  pieces 
of  a  drain  into  the  abscess  openings.  Then  all  the  abscesses 
are  disinfected  in  the  manner  described  above  and  an  anti- 
septic bandage  applied  (iodoform).  If  one  succeeds  in  this 
wise  in  mastering  the  progress  of  the  disease,  then  usually 
permanent  irrigation  with  salicylic  acid  will  work  admirably. 

"Large,  wide-spread  incisions  are  to  be  recommended 
under  such  circumstances,  and  one  should  not  hesitate  to  do 
as  Helferich  has  already  suggested,  under  special  conditions 
to  cut  through  the  transverse  ligament.  Helferich  recom- 
mended that  after  so  extensive  an  incision  the  ligament  and 
the  wound  should  soon  be  closed  with  a  secondary  suture,  if 
the  phlegmon  is  receding." 

The  use  of  strong  antiseptics,  particularly  5  per  cent, 
carbolic  acid,  as  suggested  by  Konig,  has  been  almost 
entirely  abandoned.  It  is  recognized  now  that  these 
antiseptics  certainly  impair  the  physiological  function  of 
the  cells  and  probably  do  as  much  harm  as  good. 

E.  Lexer-  says: 

"Good  results  may  be  obtained  only  by  as  early  and  as  long 
an  incision  as  possible." 

1  Speciale  Chirurgie,  vol.  in,  pp.  369,  570. 
-  Speciale  Chirurgie,  1902,  p.  726. 


238     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 
B.  Till  ma  ns^  says: 

"In  light  cases  one  treats  an  acute  non-suppurative  carpal 
bursitis  by  a  high  vertical  position  on  a  splint,  and  ice.  If 
improvement  does  not  follow,  if  suppuration  threatens,  or 
if  it  has  already  started,  one  should  open  the  synovial  sac 
by  extensive  incisions  above  and  below  the  anterior  annular 
ligament,  drain  it  and  apply  an  aseptic  bandage,  preferably 
with  a  higher  vertical  position  on  the  suspension  splint, 
according  to  von  Volkmann.  Strict  precautions  should  be 
taken  against  an  extension  of  the  suppuration,  for  example, 
to  the  forearm." 

P.  L.  Friedrich-  expresses  himself  as  follow^s: 

"If  the  inflammatory  process  finally  extends  upward  under 
the  carpal  ligament  and  in  the  manner  just  described  reaches 
the  subfacial  muscular  interstices  of  the  arm,  the  only  advice 
one  can  give  is  to  go  down  with  knife  and  dressing  forceps 
into  each  suspected  focus  of  infection,  with  careful  considera- 
tion of  the  nerves  and  vessels,  and  to  drain  effectually  with 
a  not  too  thin  drainage  material  which  will  not  be  pasted 
together  by  taut  portions  of  the  tissue.  If  it  is  not  possible 
to  guarantee  the  outflow  of  the  pus  in  a  short  time  to  such  an 
extent  in  the  region  of  the  transverse  ligament,  consideration 
of  the  danger  to  the  carpal  joints  demands  the  cutting  of  the 
transverse  ligament  (Helferich,  Konig)." 

Friedrich's  article  demonstrates  that  even  at  the 
present  time  there  is  a  tendency  to  blind  dissection  in 
this  case.  The  same  may  be  said  of  the  articles  appearing 
in  the  later  symptoms  of  surgery  emanating  from  American 
authors. 

P.  Mauclaire,^  in  a  similar  French  system  of  surgery 
(we  find  a  very  similar  description  by  Lyot),  gives  the 
following  description  of  treatment: 

'   Lehrbuch  der  speciellen  Chiriirgic,  1901. 

2  Von  Bergmann,  v.  Bruns,  v.  Mikulicz,  Handbuch  der  praktischen  Chirurgie, 
1901,  vol.  iv,  p.  420. 
^  Dentil  et  Delbet,  Traite  de  chirurgie,  1901,  vol.  x,  and  vol.  iii,  p.  850, 


EXCERPTS  FROM  THE  LITERATURE  m 

"As  for  the  subaponeurotic  abscess,  if  it  is  a  question  of 
deep  lymphangitis,  or  of  suppurative  synovitis,  the  incision 
should  be  made  where  there  is  fluctuation,  and  the  region 
drained,  it  being  possible  for  the  same  drain  to  go  from  the 
palmer  region  to  the  antibrachial  region.  In  making  this 
incision  one  should  guard  the  bloodvessels,  the  nerv^es,  and 
the  tendons.  One  often  finds  a  focus  of  suppuration  in  the 
forearm,  in  the  median  line  in  front  of  the  pronator  quadratus, 
or  sometimes  between  this  muscle  and  the  interosseous 
membrane. 

"To  open  this  focus,  one  should  make  an  incision  either 
on  the  center  of  the  anterior  face  of  the  wrist  along  the  inner 
edge  of  the  palmaris  longus,  or  longitudinally  along  the 
internal  border  of  the  wrist ;  by  approximately  following  the 
anterior  face  of  the  ulna,  one  makes  a  path  between  the  deep 
flexor  and  the  pronator  quadratus  (Parona)." 

F.  Lejars^  gives  the  following  advice  for  the  treatment 
of  deep  phlegmon  of  the  hand: 

"One  must  open  the  palm,  the  great  palmar  sheath  then 
above  the  wrist,  incise  the  superior  extension,  the  antibrachial 
cul-de-sac  of  the  abscess;  and  last  from  one  opening  to  the 
other  pass  a  drain.  An  operation,  indeed,  a  difficult  operation 
in  such  a  position,  yet  an  operation  of  immediate  urgency,  if 
one  wants  to  save  this  hand.  This  done,  place  the  member 
in  a  continuous  bath,  leave  it  for  hours  in  the  liquid,  which 
one  renews  from  time  to  time  to  keep  the  temperature  the 
same.  This  will  be  the  best  after-treatment  of  the  operation 
which  you  have  just  made." 

Lejar's  procedure  is  one  that  can  be  carried  too  far, 
since  the  development  of  granulation  tissue  may  be 
excessive,  and  in  my  opinion  the  treatment  should  be 
abandoned  after  twenty-four  to  fort3'-eight  hours,  when 
the  process  is  found  to  have  come  to  a  standstill.  After 
that  the  hot  bath  may  be  used  at  the  time  of  dressing 
only. 

'  Traite  de  chirurgie  d'urgence,  Paris,  1901. 


240     TREATMENT  OF  SUPPURATIVE  TENOSYNO\ITIS 

In  a  treatise  on  the  treatment  of  serious  phlegmons, 
deliv^ered  in  the  Naturforscherversammlung  in  Halle,' 
1891,  Helferich,  of  Griefswald,  explains  his  methods  as 
follows:  As  example,  he  takes  a  phlegmon  of  the  hand 
and  forearm,  resulting  from  a  penetrating  injury  to  the 
little  finger,  and  em])hasizes  that  such  a  case,  a  well  as  a 
crushed  fracture,  should  be  opened  as  quickly  as  possible 
to  prevent  the  spreading  and  further  resorption  of  the 
poisonous  matter  and  the  inflammatory  disturbances  of 
tendons  and  connective  tissue. 

"After  the  usual  preparations  for  the  operation  (bath, 
deep  narcosis,  cleaning  of  the  operative  field,  application  of 
Esmarch's  bandage),  he  makes  an  extensive  incision  at  the 
point  of  infection,  that  is,  for  example,  on  the  little  finger, 
which  runs  to  the  side  of  the  flexor  tendon  longitudinally. 
An  assistant  carefully  draws  apart  the  edges  of  the  wound, 
which  are  al  first  only  slightly  gaping,  with  two  little  hooks. 
If  the  suppurative  channel  is  opened  either  beside  or  within 
the  tendon  sheath,  the  careful  introduction  of  a  sound  serves 
to  control  the  direction  of  the  knife  and  scissors.  The  prepa- 
rations noted  having  been  made,  one  continues  the  incision 
farther  into  the  palm  of  the  hand,  sparing  only  the  tendons, 
nerves,  and  large  vessels,  through  the  anterior  annular  liga- 
ment over  the  volar  side  of  the  forearm.  Here,  in  case  of  a 
phlegmon  extending  from  the  little  finger,  one  keeps  to  the 
ulnar  side  of  the  common  flexors,  continuing  upward,  the 
region  having  been  prepared  below.  If  it  is  a  question  of  a 
phlegmon  on  the  thumb  side  of  the  hand  and  the  radial  side 
of  the  forearm,  one  would  proceed  accordingly,  but  following 
the  same  principles.  The  object  is  complete  exposure  of  the 
suppurative  foci  and  the  prevention  of  the  infiltration  of  pus 
into  the  intermuscular  layers  of  connective  tissue.  Often 
enough  a  focus  somewhat  encapsulated  by  the  stocking 
together  of  the  edges  is  found  between  the  muscles,  and  e\en 
under  the  flexor  profundus  digitorum,  so  that  the  inter- 
osseous membrane  is  widely  laid  ojX'n.  I'lnvard  the  incision 
first  comes  to  an  end  when  a  thorough  examination  of  the 

•   Berl.  kliii.  Wctiiischr.,  1892,  No.  4. 


EXCERPTS  FROM   THE  LITERATURE  241 

tissue  and  the  palpation  of  the  adjoining  region  leads  one  to 
expect  healthy  conditions. 

"So  far  as  necessary,  other  incisions  are  added  to  this  large 
one,  either  on  the  other  side  of  the  palm  or  on  the  dorsal 
side." 

He  is  decidedly  against  any  other  treatment  of  this 
process,  and  has  never  seen  any  good  results  from  small 
punctures;  small  incisions  and  drainage  cannot  effect 
nearly  as  much.  Disinfection  of  the  wound  is  dispensed 
with,  and  he  confines  himself  to  a  careful  washing  out  with 
a  6  per  cent,  salt  solution,  emphasizing  the  local  injuries, 
irritating  effect  of  antiseptics  and  the  very  unfa\'orable 
effect  of  the  same  on  the  kidneys. 

In  the  after-treatment  he  emphasizes  passi\e  move- 
ments, baths,  active  movements  in  water-baths,  massage, 
electricity,  occasional  compression,  and  nightly  fixation 
in  various  positions. 

Helferich  then  recommends  an  apparatus  invented  by 
Dr.  Krukenberg  for  the  development  of  passiye  move- 
ments. 

C.  L.  Schleich^  says  in  speaking  of  the  treatment  of 
phlegmons  of  the  palm  of  the  hand: 

•  "If  we  cut  through  the  ligament  we  can  prepare  for  the 
most  serious  functional  disturbances;  if,  on  the  other  hand, 
we  do  not  follow  up  the  channel  of  suppuration  we  leave  a 
great  mortal  danger.  To  decide  this  matter  we  press  firmly 
on  the  tendinous  convolutions  above  the  ligament  of  the  fore- 
arm and  press  out  the  contents  toward  the  periphery;  we 
will  suppose  that  no  drop  of  pus  flows  from  the  tendon  pocket 
below  the  ligament.  We  are  then  obliged  to  make  a  counter- 
opening  above  the  ligament,  which  would  have  been  abso- 
lutely necessary  in  the  presence  of  pus  above  the  same.  I 
depend  on  the  appearance  of  this  superligamentary  flexor 
swelling  to  decide  whether,  through  a  counter-opening,  I  shall 
pass  a  drain  of  gauze  strip  under  the  ligament,  or  whether 

1  Xeue  Methoden  der  Wundheilung,  Berlin,  1899. 
I6 


242      TREATMEXr  OF  SUPPURATIVE  TENOSYNOVITIS 

I  shall  cut  through  the  ligament  to  further  lay  bare  the 
avenues  of  infection.  In  case  of  dry  opacity  and  scarring, 
I  usually  let  gauze  drainage  sufifice;  if,  however,  fluid  pus  is 
found  between  the  tendons,  I  stand  for  unconditional  severing 
of  the  ligament  and  further  following  up  the  avenues  of  infec- 
tion." 

K.  Poulsen  (quoted  from  Forssell)  gives  the  following 
description  of  the  opening  of  the  ulnar  tendon  sheaths: 

"If  the  sheath  is  swollen,  or  the  skin  edematous,  it  is  not 
so  easy  to  see  what  one  is  about  or  to  say  exactly  what  flexor 
tendon  lies  before  him  while  he  is  making  the  incision;  yet  in 
these  cases  it  is  of  no  great  importance  if  one  should  happen 
to  get  in  between  the  deep  flexor  tendons  of  the  second  and 
third  fingers;  the  sheath  when  it  is  stretched  is  always  opened, 
if  one  only  gets  in  between  the  tendons  of  the  deep  flexor 
muscles.  The  incision  is  then  made  in  the  following  manner: 
The  arm  is  rendered  bloodless,  and  then  one  determines  the 
position  of  the  M.  flexor  ulnaris  with  the  help  of  the  os  pisi- 
forme,  its  point  of  insertion,  and  of  the  tendon  of  the  M. 
flexor  carpi  radialis  by  drawing  a  line  upward  from  the  second 
metacarpal  joint,  to  whose  base  it  is  attached.  Half-way 
between  these  two  tendons  an  incision  is  made  to  the  liga- 
mentum  carpi  volare  proper;  hooks  are  used  to  widen  the 
wound,  with  the  radial  (side)  one  must  be  very  careful  on 
account  of  the  median  nerve.  Next,  he  proceeds  into  the 
depth  between  the  tendons,  first  the  superficial  ones,  then  the 
deep-lying  ones;  when  the  connective  tissue  which  binds 
together  the  deep  tendons  has  been  passed,  the  sheath  is 
opened,  the  pus  streams  out,  while  with  a  Lister's  forceps  the 
opening  of  the  sac  is  dilated  upward  and  downward;  after 
this  iodoform  gauze  is  laid  in,  the  bandage  removed,  and  the 
bleeding  stopped  by  compression. 

"As  a  bandage  I  usually  use  a  boric  acid  application  which 
is  changed  daily.  The  gauze  remains  undisturbed  until  it 
loosens  of  itself;  and  as  a  support  for  the  hand,  a  volar  splint 
is  used.  Some  prefer  to  make  an  opening  upon  a  bulb- 
headed  probe  previously  introduced  in  the  vola  manus  on 
the  lower  border  of  the  ligamentum  carpi  volare  proper,  and 
to  draw  a  drain  in  between  the  two  openings.  Yet  I  must 
say  that  I  have  no  particular  fondness  for  using  drains  in  this 


EXCERPTS  FROM  THE  LITERATURE  243 

place,  as  they  easily  compress  the  tendons  in  this  compara- 
tively narrow  canal  and  thereby  give  rise  to  necrosis.  If  the 
incision  has  been  made  above  the  ligament,  and  along  the 
tendon  to  the  little  finger,  there  will  be  an  upper  and  lower 
opening  of  the  bursa,  which,  without  danger  to  the  tendons, 
can  be  held  open  by  gauze  drainage,  and  offers  sufficient 
outlet  for  the  pus,  at  least  so  long  as  the  pus  confines  itself 
to  the  sheath  alone.  If  the  suppuration  lasts,  I  prefer  to 
split  the  ligamentum  carpi  volare  proper  and  lay  open  the 
canals;  it  is  not  rare  to  succeed  in  this  way  in  rescuing  the 
tendons  which  at  this  point  have  a  fairly  large  vessel  lying  in 
mesotendon." 

K.  Poulsen  has  also  discussed  the  therapeutics  of 
tendovaginitis  of  the  thumb  and  radial  bursa.  He  opens 
the  finger  tendon  sheath  to  the  lower  edge  of  the  M. 
adductor  poUicis  and  the  radial  bursa  above  the  ligament, 
•avoids  drainage  tubes,  and  in  their  place  uses  gauze 
drainage. 

"In  cases  of  persistent  suppuration  the  ligament  is  cut 
and  a  peritendinous  phlegmon  is  mastered  by  continuing 
the  incision  on  the  thumb  along  the  lower  border  of  the  abduc- 
tor, and  laying  in  drains  when  it  is  seen  that  the  tendon  will 
be  lost;  the  cutting  through  of  the  muscular  system  of  the 
thenar,  used  by  some,  should  be  resorted  to  only  in  desperate 
cases,  because  it  destroys  in  large  measure  the  function  of  the 
abductor." 

It  would  seem  from  this  that  Poulsen,  at  least  in 
coincident  infections  of  the  tendon  sheath  of  the  thumb 
and  the  radial  bursa,  opens  the  latter  only  above  the 
ligament^  and  exposes  that  part  of  the  bursa  which  lies 
wdthin  the  thenar,  only  when  the  suppuration  has  spread 
beyond  the  bursa.  In  cases  of  persistent  suppuration  the 
ligament  is  cut;  but  he  does  not  state  whether,  after  this 
tardy  fissure  of  the  ligament,  he  has  found  the  flexor 
tendon  of  the  thumb  and  the  thenar  nerves  capable  of 
carr^'ing  on  their  work  or  not. 


244     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

"\\'hy  it  should  ever  be  necessary  to  split  the  thenar 
muscles  after  cleaving  the  ligament  I  cannot  see,  as  only  a 
small  upper  point  covers  the  radial  bursa  below  the  ligament. 
Nor  is  it  clear  why  such  a  fissure  of  the  muscles  in  question 
should  destroy  a  great  part  of  their  functional  activity;  but 
the  incision,  continued  through  the  ligaments  and  all  the  soft 
parts,  including  the  tendon  sheath,  cuts  through  the  nerves, 
not  only  of  the  M.  adductor,  but  also  of  the  Al.  opponens  and 
of  the  superficial  part  of  the  M.  flexor  brevis,  and  thus  causes 
a  very  troublesome  crippling  of  the  thumb. 

"Finally,  to  use  this  method  of  operation  in  'desperate' 
cases  will  not  save  the  tendon  of  the  thumb;  it  is  undoubtedly 
better  to  remove  the  tendon,  which  in  such  a  case  would 
undoubtedly  be  destroyed  or  rendered  useless  at  this  late 
date." 

To  open  the  upper  end  of  the  radial  bursa,  Max  Schiiller 
proceeds  as  follows :  The  incisions  are  best  made  outward 
(toward  the  radial  side)  on  the  forearm,  beginning  at  the 
radial  artery  and  extending  along  it. 

Nicaise,  on  the  other  hand,  places  the  incision  between 
the  arterioradialis  and  the  tendon  of  the  M.  flexor  carpi 
radialis,  and  between  the  latter  and  the  tendon  of  the  M. 
palmaris  longus. 


CHAPTER  XVI. 

THE  TREATMENT  OF  ACUTE  SUPPURATIVE 
TENOSYNOVITIS— DISCUSSION  OF 
TECHNIQUE. 

Following  the  anatomical  investigations  detailed  in 
the  previous  chapters  and  a  careful  study  of  all  clinical 
cases  coming  under  observation,  certain  procedures  were 
instituted,  which  in  m}-  hands  have  given  most  satis- 
factory results.  The  technique  which  I  have  used  in 
these  serious  cases  is  herewith  described.  This  may  be 
classified  under  three  heads: 

1.  In  the  early  hours  while  the  diagnosis  may  be  in 
doubt. 

2.  When  the  symptoms  and  signs  of  tenosynovitis  are 
marked. 

3.  After-treatment. 

TREATMENT  WHILE  THE  DIAGNOSIS  MAY  BE  IN  DOUBT. 

While  commonly,  when  a  finger  is  infected,  it  is  some 
days  before  the  tendon  sheath  becomes  involved;  it  may 
be  early,  but  when  it  is  invaded  the  symptoms  develop 
rapidly  because,  as  was  mentioned  above,  there  is  so  little 
resistance  that  the  infection  spreads  throughout  the 
sheath  in  a  short  time.  However,  during  the  preliminary 
stage,  much  may  be  done  to  prevent  a  spread  into  the 
sheath.  The  best  sort  of  application  is  undoubtedly  some 
form  of  moist,  hot  dressing.  Boric  acid  solution  in 
saturated  strength  is  most  commonly  used,  but  any  of  the 
other  solutions  in  common  use  are  probably  just  as 
efhcient.  Carbolic  acid  dressing  in  any  form  should  be 
avoided    because    of    the    danger    of    gangrene.     Local 


246    TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

painting  with  ichthyol,  iodine,  and  such  irritating  solu- 
tions is  absolutely  useless.  German  surgeons  speak 
highly  of  95  per  cent,  alcohol  dressings  left  on  twenty-four 
hours.  They  probably  are  no  more  efficient  than  the  hot 
boric  solution  and  are  always  a  source  of  some  anxiety, 
owing  to  the  possible  danger  of  their  catching  fire,  as 
occurred  in  one  instance  that  came  to  my  attention. 
Probably  the  next  most  essential  procedure  is  to  keep  the 
part  at  rest;  this,  of  course,  is  indicated  in  any  infection, 
since  the  muscular  action  tends  to  disseminate  the  germs, 
thus  extending  the  area  to  be  walled  off  by  the  leukocytes 
carried  in  by  the  dilatation  of  the  vessels  incident  to  the 
hot  dressings.  Elevation  of  the  parts  is  recommended 
by  many,  but  personally  I  could  never  see  any  advantage 
in  it  except  to  make  the  arm  comfortable,  and  it  is  true 
the  elevation  of  the  hand  is  sometimes  necessary  for  this. 
If  the  infection  is  severe,  put  the  patient  in  bed.  Keep  the 
bowels  open  and  the  kidneys  active.  Preserve  the  nutri- 
tion of  the  patient.  The  methods  of  Bier  and  Klapp  are 
discussed  above. 

TECHNIQUE  OF  TREATMENT  AFTER  DIAGNOSIS  IS  MADE. 

The  diversity  of  opinions  as  to  the  proper  methods  of 
treatment  held  by  various  surgeons,  as  noted  above,  is 
sufficient  proof  of  the  severity  of  this  condition  and  the 
difficulty  of  its  treatment.  It  emphasizes  the  frequency 
of  bad  functional  results  and  should  stimulate  us  to  most 
careful  study  of  our  cases. 

The  diagnostic  acumen  of  the  operator  cannot  but  be 
a  vital  factor  in  the  treatment.  It  is  probable  that  too 
many  will  err  on  the  side  of  conservatism  in  the  treatment 
of  the  first  cases  of  tenosynovitis  that  are  met.  It  will  be 
reasoned  that  since  some  damage  already  will  have 
occurred  to  the  tendons,  if  they  are  involved,  a  few  hours' 
delay  will  not  add  seriously  to  the  condition.  This 
possibility  will  be  preferred  to  that  of  opening  and  infect- 


TECH  NIC  OF  TREATMENT  AFTER  DIAGNOSIS      247 

ing  an  uninvolved  sheath.  However,  these  few  hours  are 
of  great  importance  in  the  fuhninating  type,  and  operation 
should  be  most  prompt. 

I  do  not  intend  this  as  advocacy  of  operation  regardless 
of  accurate  diagnosis,  but  as  a  stimulus  to  careful  study 
to  the  end  that  the  surgeon,  being  better  qualified,  may 
neither,  by  ill-advised  conservatism,  delay  necessary 
operation,  nor  by  thoughtless,  audacious  incisions  jeopar- 
dize the  usefulness  of  a  healthy  hand. 

My  own  opinions  as  to  the  best  methods  are  based 
upon  ni}'  anatomical  researches  and  upon  obser\'ation 
of  the  patients  presenting  themselves  at  the  dispensary 
and  hospital  of  the  Post-Graduate  Medical  School  and 
Hospital,  at  Wesley  Hospital,  and  the  Northwestern 
University  Medical  School.  To  Professors  Besley  and 
Richter,  and  others  of  my  friends  at  these  hospitals  and 
at  the  Cook  County  Hospital,  I  wish  to  acknowledge 
my  appreciation  of  the  opportunity  for  the  study  of  their 
cases  in  addition  to  my  own.  Concerning  the  technique 
of  treatment,  undoubtedly  the  future  has  much  in  store 
for  us  that  we  cannot  know  at  the  present  time.  The 
subject  is  one  not  only  of  local  condition,  but  of  the 
resistance  of  the  individual  and  his  reaction  to  various 
toxins.  In  other  words,  the  newer  problems  in  serum 
pathology  must  first  be  worked  out  before  we  can  attain 
the  best  results.  I  cannot  but  feel,  however,  that  even 
the  local  conditions  are  not  so  well  understood  by  the 
average  surgeon  as  is  possible,  and  that  our  bad  results 
w^ould  be  reduced  at  least  by  half  if  more  study  were  given 
to  careful  diagnosis. 

I  have  secured  the  best  results  by  the  following  pro- 
cedures. Operation  should  always  be  done  under  general 
anesthesia  and  in  a  bloodless  field.  Where  possible,  the 
gas-oxygen  anesthesia  is  to  be  preferred  to  ether.  Where 
the  process  is  especially  virulent  and  acute,  I  leave  on 
the  Esmarch  bandage  for  twelve  to  eighteen  hours  after 


248     TREATMENT  OF  SUPPURATIVE  TEXOSYXOVITIS 

the  operation.  Care  is  taken,  however,  to  loosen  it  so 
as  to  produce  a  passive  hyperemia.  In  other  words,  a 
Bier's  hyperemia  is  secured  for  this  time.  This  is  done 
not  so  much  for  the  therapeutic  effect  as  to  prevent  the 
rapid  absorption  of  virulent  toxins.  I  hope  in  this 
manner  to  give  the  patient  time  to  react  and  develop 
antitoxins  to  overcome  the  poison  rather  than  allow  him 
to  be  overwhelmed  by  a  large  amount  of  virulent  toxin 
absorbed  at  one  time. 


Treatment  of  Tenosynovitis  of  the  Index,  Middle  and  Ring 

Fingers. 

The  procedure  will  vary  according  to  the  form  of 
infection  and  the  amount  of  destruction  present.  The 
first  incision  is  made  at  the  site  of  known  infection,  open- 
ing the  sheath  at  the  side  and  not  in  the  median  line, 
cutting  the  length  of  the  shaft  of  the  proximal  or  middle 
phalanx,  and  leaving  the  part  over  the  articulation  uncut 
so  that  the  tendon  does  not  prolapse,  unless  there  is  doubt 
as  to  the  freedom  of  drainage.  I  wish  to  insist  that  the 
first  requisite  is  adequacy  of  the  opening  for  drainage,  since 
a  small  incision  soon  becomes  closed  by  prolapsing  tissue. 
Make  the  incision  too  free  rather  than  too  small.  In  those 
cases  where  it  has  seemed  advisable  to  incise  the  length 
of  the  sheath,  which  I  do  in  case  of  doubt,  I  have  found 
the  finger  in  an  extended  position  if  there  is  a  tendency  of 
the  tendons  to  prolapse.  After  having  opened  the  sheath 
at  this  one  point,  pressure  upon  its  various  parts  will  give 
one  some  idea  of  the  extent  of  the  invasion.  If  it  is 
complete,  as  is  generally  the  case,  a  similar  incision  is 
made  over  the  uncut  proximal  or  middle  phalanx.  No 
incision  is  necessary  over  the  distal  phalanx,  and  in  mak- 
ing this  I  feel  that  Klapp  is  in  error  if  his  drawing  repre- 
sents his  technique  correctly.  Over  the  proximal  end  of 
the  sheath,  at  the  base  of  the  palm,  the  technique  will 


TREATMENT  OF   TEXOSYXOVITIS  OF^FIXGERS      249 

var>'  according  to  the  extent  of  the  invasion.  If  early, 
the  incision  is  made  over  the  middle  of  the  sheath  at  its 
end  in  the  palm,  carr^'ing  it  from  the  flexion  crease  at  the 
base  of  the  proximal  phalanx  for  about  three-fourths  of 
an  inch  into  the  palm.  If,  however,  there  is  some  ques- 
tion whether  the  lumbrical  spaces  at  the  sides  have  begun 
to  become  involved  {vida  supra),  the  incision  is  made 
upon  the  side  most  affected,  opening  the  space  and  the 
tendon    sheath    at    the    same    time.     If    both    sides    are 


Fig.  94. — Lines  show  area  of  possible  incisions  for  infections  of  the  various 
tendon  sheaths.  In  case  of  doubt  the  free  incision  of  the  ivhole  sheath  is  to  be  advised. 
(See  text  for  full  description.) 

involved,  two  incisions  are  made.  The  finger  is  now 
cleansed  and  examined.  If  there  is  much  involvement  of 
the  synovial  surfaces,  or  if  there  is  much  edema  of  the 
finger,  ^vhich  would  tend  to  close  the  incisions,  I  connect 
the  two  first  incisions  made,  thus  making  one  incision  the 
length  of  the  sheath  rather  than  multiple  i^tcisions  on  both 
sides  of  the  finger. 

I  have  tried  cutting  down  to  the  sac  in  doubtful  cases, ^ 
then  inserting  an  aspirating  needle  and  attempting  to 

1  White,  Whitlow  and  its  Treatment,  Brit.  Med.  Jour.,  February  24,  1906, 


250    TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

draw  off  some  pus  for  diagnostic  purposes,  hoping  by  this 
procedure  to  avoid  the  possibility  of  infecting  an  unin- 
volved  sheath  through  opening  it  with  a  scalpel.  While, 
theoretically,  the  procedure  would  appear  to  be  advisable, 
practically  it  is  of  little  aid.  The  bulging  of  the  sheath, 
proving  the  presence  of  fluid  under  tension,  is  generally 
easily  seen,  while  a  failure  to  secure  pus  is  not  sufficient 
evidence  of  its  absence. 

When  the  Involvement  of  Adjacent  Areas  Has 
Begun. — The  involvement  of  the  articulation  between 
the  middle  and  proximal  phalanges,  which  occurs  in  late 
cases,  will  be  discussed  in  the  chapter  dealing  with 
complications  and  sequelae  (Chapter  XXIX).  The 
method  of  treatment  will  be  outlined  there.  I  shall 
only  add  to  what  I  have  already  said,  that  if  early  incision 
of  the  sheath  is  made  this  involvement  is  generally  pre- 
vented: another  reason  for  early  incision.  As  has  been 
pointed  out,  the  paths  of  extension  in  the  involvement  of 
the  lumbrical  spaces  vary  in  the  individual  fingers.  • 

The  Index  Finger. — When  the  infection  passes  to  the 
lumbrical  space  on  the  outer  side,  it  may  extend  into  the 
thenar  space,  and  the  incision  which  opens  the  lumbrical 
space  can  extend  up  into  the  thenar.  Pressure  upon  the 
thenar  area  will  force  pus  out  along  the  line  of  incision. 
This  is  then  extended  along  the  radial  side  of  the  meta- 
carpal bone,  the  incision  lying  dorsal  to  the  web  which 
extends  from  the  thumb  to  the  base  of  the  index  finger. 
The  artery  forceps  is  then  carried  across  the  palmar 
surface  of  metacarpal  bone  and  the  blades  opened,  thus 
draining  the  thenar  space  without  an  incision  upon  the 
palmar  surface  (Figs.  io6  and  112).  Care  should  be  used 
not  to  force  the  point  of  the  forceps  beyond  the  middle 
metacarpal  bone;  otherwise  the  middle  palmar  space  will 
be  entered  and  an  extension  to  this  space  favored. 

When  the  extension  has  entered  the  lumbrical  space 
between  the  index  and  middle  finger,  the  incision  should 


TREATMENT  OF  TENOSYNOVITIS  OF  FINGERS      251 

be  made  into  the  sheath  at  its  uhiar  side,  thus  opening 
both  the  sheath  and  the  lumbrical  canal  through  the  same 
skin  incision.  If  the  lumbrical  canal  is  badly  involved, 
the  pus  may  have  extended  distally  into  the  loose  mesh  of 
tissue  at  the  web  or  proximally.  If  distally,  it  may  be 
necessary  to  add  a  second  incision  upon  the  dorsum 
between  the  bases  of  the  index  and  middle  fingers,  and 
procure  through-and-through  drainage  of  the  web,  or  at 
times  I  have  split  the  web  completely  and  have  not  as  yet 
observed  any  serious  impairment  of  function  following 
(Fig.  112). 

If  the  infection  extends  proximally  along  the  lumbrical 
space  between  the  index  and  middle  finger  some  care 
should  be  used  in  the  incision,  since  while  it  practically 
always  involves  the  thenar  it  may  involve  the  middle 
palmar  space.  After  the  lumbrical  canal  is  opened, 
pressure  over  these  areas  will  demonstrate  which  is  in- 
volved, since  pus  will  exude  into  the  incision.  If  the 
thenar  space  is  involved,  after  opening  the  lumbrical 
space  freely  the  thenar  space  is  opened  by  an  incision 
upon  the  dorsal  surface  between  the  metacarpal  bones  of 
the  thumb  and  index  finger,  i.  e.,  drainage  of  the  thenar 
space  as  described  above  and  also  in  Chapter  XVII. 
In  those  exceptional  cases  in  which  the  middle  palmar 
space  is  involved  the  lumbrical  incision  is  supplemented 
by  an  incision  over  the  middle  palmar  space  following 
up  the  lumbrical  space  between  the  middle  and  ring 
finger  as  described  below  under,  "The  Middle  Finger." 
(A  more  extended  discussion  is  found  in  Chapter  XVII.) 

The  Middle  Finger. — When  extension  occurs  into  the 
lumbrical  canal  upon  the  radial  side,  or  the  web  on  either 
side,  the  technique  of  treatment  is  that  just  described. 
When  the  extension  is  along  the  lumbrical  canal  between 
the  middle  and  ring  fingers  toward  the  palm,  early  the 
pus  may  be  between  the  palmar  fascia  and  the  tendon 
in  the   "loft,"   as  already  described,   but  it  very  soon 


252    TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

involves  the  middle  palmar  space.  Here  the  incision  is 
carried  one-quarter  inch  into  the  palm,  i.  e.,  proximal  to 
the  transverse  line  joining  the  ends  of  the  flexion  creases. 
If  pus  is  expressed  through  this  from  the  palm,  an  artery 
forceps  is  inserted  under  the  tendons  going  to  the  ulnar 
side  and  the  blades  opened.  No  drainage  is  inserted, 
although  in  a  few  instances  I  have  placed  in  the  pocket 
small  strips  of  rubber  dam  or  gauze  thoroughly  impreg- 
nated with  vaseline.  Ordinary  gauze  acts  simply  as  a 
plug,  and  I  never  use  it. 

The  Ring  Finger. — Here  the  extension  to  the  web  or 
into  the  palmar  space  from  either  side  is  treated  by  the 
same  technique  as  described  above. 


Treatment  of  Tenosynovitis  of  the  Little  Finger  and  Ulnar 

Bursa. 

If  the  finger  alone  is  involved,  the  treatment  is  the 
same  as  that  noted  above  for  the  other  fingers,  except 
that  almost  always  it  will  be  found  advisable  to  make 
a  single  incision  on  the  lateral  surface  the  length  of  the 
two  proximal  phalanges,  since  we  wish  to  procure  per- 
fect drainage,  and  thus  avoid  possible  extensions.  In  a 
few  of  the  cases  there  is  a  congenital  separation  of  the 
proximal  from  the  distal  portion  at  approximately  the 
metacarpo-phalangeal  articulation,  and  in  a  certain  pro- 
portion of  these  cases  in  which  there  is  no  separation  the 
opening  is  so  narrowed  that  there  is  a  temporary  dam 
produced  by  serous  adhesions  if  the  inflammation  is  not 
too  fulminating  in  character,  which  unfortunately  it 
generally  is.  In  the  former  condition  there  is  little  like- 
lihood of  a  spread  to  the  ulnar  sheath,  so  that  we  should  be 
extremely  careful  not  to  open  this  sheath  unless  we  are 
certain  that  it  has  become  infected,  since  we  are  exposing 
the  patient  to  grave  danger.  On  the  other  hand,  if  the 
occlusion  is  of  temporary  inflammatory  origin,  we  can  see 


TENOSYNOVITIS  OF  FINGER  AND  ULNAR  BURSA    253 

readily  how  important  it  is  that  an  early  diagnosis  of  the 
condition  should  be  made  and  proper  treatment  of  the 
distal  portion  instituted  to  prevent  a  spread  to  the  ulnar 
sheath.  As  to  just  what  the  proper  procedure  should  be, 
in  case  we  are  fairly  certain  that  there  is  an  infection  of  the 
distal  portion  of  the  sheath  and  we  are  still  in  doubt  as  to 
whether  it  has  extended  to  the  proximal  or  palmar  portion 
or  not,  there  is  room  for  discussion. 

Forssell  advises  that  we  should  begin  at  the  point 
where  we  are  least  sure  of  infection,  while  Helferich 
suggests  that  w^e  begin  at  the  point  of  infection  where 
we  are  sure  and  make  our  way  along  with  care.     Naturally 


Fig.  95. — Lines  represent  the  various  incisions  made  for  infections  ^of  the 
tendon  sheaths  and  their  possible  extensions  into  the  forearm.  (See  text  for 
complete  description.) 

we  would  admit  the  former  to  be  the  proper  method  if 
certain  unknown  equations  <iid  not  enter  into  the  discus- 
sion. In  the  first  place,  what  proportion  of  aseptic  ulnar 
sheaths  can  be  opened  and  not  infect  the  sheath  from  the 
lymphatics  which  are  constantly  carrying  germs  from  the 
point  of  infection  through  the  subcutaneous  tissue  in 
which  our  so-called  aseptic  incision  is  made?  Upon  the 
answer  to  this  question  depends  in  all  probability  the 
proper  solution  of  the  question,  and  it  will  take  a  large 
number  of  carefully  observed  cases  to  arrive  at  a  decision. 
Increasing  experience,  however,  has  confirmed  me  in  the 
opinion  that  it  is  wiser  to  incise  at  a  known  point  of 


254    TREATMEXT  OF  SUPPURATIVE  TEXOSVXOVITIS 

involvement.  This  pocket  being  opened,  pressure  is 
exerted  over  the  sites  of  predilection  in  continuity.  If 
they  are  involved,  pus  will  be  seen  to  enter  the  previously 
opened  site.  A  grooved  director  is  now  inserted  along  the 
canal  and  the  incision  continued  or  the  focus  opened  by 
the  ])roper  methods. 

When  the  continuation  of  this  sheath  in  the  hand  is 
involved,   the  palmar  portion  is  opened  by  an  incision 


Extensor  communis 
Synovial  sheath, 


Extensor  minimi  digit 


Extensor  carpi  ulnaris 


Hyputhenar  muscles 
with  intermuscular' 
spaces 


Ulnar  vessels  and  net 


I  Extensor  secundi  internodii 
pollicis 

■Middle  palmar  space 


Extenior  carpi  radiaiis 
brevior 


Extensor  carpi  radiaiis 

longior 
Radial  vessels  and 

nerve 


Extensor  primi 
internodii  pollicis 


Thenar  muscles 


Ulnar  buna 


I 
Palmaris  longus' 


\  Flexor  longus  pollicis 

I  Synovial  sheath 

Median  nerve  and  vessels 


Fig.  96. — Cross-section  No.  VIII.     The  ulnar  bursa,  radial  bursa  and  inter- 
mediate sheaths  are  shown  in  red. 


extending  from  the  base  of  the  finger  at  the  distal  flexion 
crease  of  the  palm  and  passing  toward  the  base  of  the 
palm  (Fig.  95).  It  is  my  custom  to  insert  a  grooved 
director  in  the  sheath  at  this  point  and  follow  along  this, 
cutting  the  tissues  between  the  sheath  and  the  surface, 
having  the  thought  in  mind  to  avoid  the  tendon  and  cut 
as  far  to  the  ulnar  side  of  the  sheath  as  possible,  since 
there  will  be  better  drainage,  particularly  at  the  wrist,  if 


TEXOSYXOVITIS  OF  FIXGER  AXD   LLXAR  BURSA    255 

this  is  done  (Fig.  96).  After  the  anterior  annular  liga- 
ment is  reached,  pressure  above  over  the  prolongation  of 
the  sheath  in  the  forearm  will  force  pus  downward  into  the 
sheath  below  the  ligament  if  the  infection  has  extended 
here,  as  it  generally  has. 

If  an  involvement  of  the  prolongation  of  the  sheaths 
above  the  annular  ligament  or  a  forearm  involvement  is 
diagnosticated,  I  proceed  as  follows:  At  a  point  about 
one  and  one-half  inches  above  the  tip  of  the  ulna  an 
incision  about  two  inches  long  is  made  directly  down  on 
this  bone  at  its  flexor  surface,  an  artery  forceps  is  now- 
thrust  across  the  flexor  surface  of  this  bone  into  the  space 
under  the  flexor  tendons.  The  fascial  attachment  of  the 
muscle  to  the  ulna  is  incised  the  length  of  the  skin  incision. 
In  patients  with  exceptionally  large  abscesses  here  a 
second  incision  may  be  made  upon  the  radial  side,  but 
this  is  seldom  necessary.  Make  the  incision  too  long 
rather  than  too  short,  since  a  large  incision  with  free  drain- 
age will  heal  more  rapidly  than  a  small  incision  with 
inadequate  drainage.  Especial  care  should  be  used  here 
to  make  the  incision  neither  too  far  upon  the  flexor  surface 
nor  dorsally,  since  in  the  first  instance,  especially  upon 
the  radial  side,  the  artery  may  be  injured  either  by  the 
primary  incision  or  subsequent  necrosis;  and  in  the 
second  instance,  if  the  incision  is  too  far  dorsal,  it  will  not 
drain  easily.  If  the  primary  incision  is  made  low  down 
and  on  the  radial  side,  the  danger  of  injuring  the  radial  is 
greater.  With  the  proper  precaution,  no  anxiety  need  be 
felt  (Fig.  97).  Having  opened  this  area,  the  finger  is  now 
inserted  under  the  flexor  profundus  tendons,  and  if  there 
is  any  infection  of  the  sheath,  it  is  bulging  and  can  be 
opened  easily.  In  case  it  is  not  found  easily,  flexion  and 
extension  of  the  fingers  will  locate  the  tendons  involved 
and  the  palpating  finger  can  be  pushed  up  among  them, 
or  an  artery  forceps  can  be  pushed  under  the  annular 
ligament  through  the  bursa  Avhich  has  been  opened  in^the 


256    TREATMEXT  OF  SUPPURATIVE  TENOSYNOVITIS 

palm  in  front  (Fig.  98).  Its  point  is  felt  plainly  by  the 
finger  under  the  tendons,  and  the  opening  dilated  freely. 
As  a  matter  of  fact,  the  infection  will  be  found  to  have 
ruptured  into  this  space  in  practically  every  case,  except 
in  the  very  earliest  stages.  /  wish  to  emphasize  that  it  is 
upon  this  incision  that  I  depend  for  drainage  of  the  upper 
end  of  the  bursa,  since  it  extends  upward  on  the  tendons 
on  their  posterior  surface  (Fig.  98).  In  other  words,  this 
site  is  used  for  entering  and  draining  the  sheath  before 
rupture,  as  well  as  for  incision  for  draining  the  extension 


Ulnar  art;.-,^     .y-'  ii^'JB/B^^^Bi^ 

.  -Ms-clian  nerve 
^^i.^^>s'  ]2-ac/]dI  art. 

^==^^"l 

:> 

:> 

^^ 

^^"^™*^.             ^    '-^. 
*'^>^ 

-<: 

Fig.  97. — Cross-section  7  cm.  above  radial  styloid.  Artery  forceps  inserted 
transversely  in  juxtaposition  to  ulna  and  radius  through  the  anterior  interos- 
seous space,  showing  that  incision  can  be  made  here  and  not  injure  important 
vessels  and  nerves.     Notice  tissue  between  radial  artery  and  the  forceps. 


into  the  forearm.  It  will  be  remembered  that  attention 
has  already  been  drawn  to  the  fact  that  when  extension 
takes  place  this  area  between  the  flexor  profundus  tendons 
and  the  interosseous  septum  and  the  pronator  quadratus 
is  always  first  involved.  In  the  early  stages  of  rupture, 
after  having  cut  through  the  skin  and  subcutaneous  tissue, 
the  operator  will  be  inclined  to  desist,  since  no  evidence 
of  pus  will  be  found.  It  is  not  until  the  area  under  the 
profundus  is  reached  that  one  finds  the  pus.  Again,  a 
second  fallacious  reason  for  stopping  the  incision  at  this 
stage   may   be   found.     There   may   be   a   subcutaneous 


TENOSYNOVITIS  OF  FINGER  AND  ULNAR  BURSA    257 

accumulation  of  pus  on  the  flexor  surface  of  the  wrist,  in 
all  probability  of  lymphatic  origin;  this  having  been 
opened,  the  operator  feels  that  he  has  drained  a  pocket 


Deep  and  superficial  flexors.  / 


Space  lying  between  hone 
and  flex.  prof.  7miscle . 


Prolongation  of  ulnar  bursa 
under  flexor  prof,  muscle 


Ant.  annular  lig 


Palmar  fascia  ^ 


Palmar  arch  and 
digital  nerve  \ 


\_  ->  '  Pronator  quadratus  m. 


'  Ulnar  bursa 
Post,  annular  lig. 


Dorsal  sheet  of  ulnar  bursa 
impinging  on  joint 

~^  Interosseous  mu^. 


~'~'  Tendons  to  little  finger  in 
synovial  sheath 

""-,  Cut  head  of  fifth  metatarsal 


Fig.  98. — Drawing  showing  extension  of  the  ulnar  bursa  underneath  dorsal  surface 
of  the  flexor  tendons  and  space  into  which  pus  ruptures  into  forearm. 
17 


258    TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

in  direct  communication  with  the  tendon  sheath  or  may 
fear  that  his  diagnosis  of  tendon-sheath  infection  has  been 
incorrect. 

Because  of  necrosis  of  tendons  or  superficial  involve- 
ment of  the  tendons  above  the  wrist,  it  may  be  deemed 
advisable  to  make  drainage  upon  the  flexor  surface.  The 
anterior  annular  ligament  may  or  may  not  be  cut  as  is 
indicated  in  the  given  case.  If  we  wish  to  open  the 
tendon  sheath  above  the  ligament  without  cutting  it,  the 
line  of  incivsion  lies  about  one-half  inch  to  the  radial  side 
of  the  ulnar  artery.  Generally,  however,  the  swelling  is 
such  that  the  pulsation  of  this  vessel  cannot  be  felt.  It  is 
then  necessary  to  proceed  by  choosing  a  point  at  the 
junction  of  the  middle  and  ulnar  thirds  of  the  flexor 
surface  and  incising  carefully,  layer  by  layer,  until  the 
group  of  flexor  tendons  is  reached.  These  can  be  identi- 
fied by  moving  the  fingers.  The  dissection  is  now  carried 
down  along  the  ulnar  border  of  these  tendons  in  juxta- 
position to  them  and  immediately  above  the  anterior 
annular  ligament,  since  the  sheath  lies  to  the  ulnar  side 
and  posterior  to  the  tendons.  If  infected,  it  should  be 
freely  opened,  since  the  swelling  due  to  edema  and 
inflammatory  infiltration  tends  to  close  a  small  opening. 
If  the  infection  is  now  seen  to  be  at  all  severe,  the  anterior 
annular  ligament  is  split  as  far  to  the  ulnar  side  as  possible. 
The  hook  of  the  unciform  interferes  somewhat  with  the 
incision.  If  it  is  determined  when  the  palmar  part  is 
first  incised  that  the  anterior  annular  ligament  shall  be  cut, 
one  proceeds  differently.  The  incision  is  continued  from 
below  upward,  carrying  the  incision  about  an  inch  up  on 
the  forearm.  This  latter  is  made  as  much  to  drain  the 
subcutaneous  area  above  the  wrist,  which  commonly 
becomes  infected,  as  to  open  the  sheath.  This  method  of 
drainage  of  the  upper  part  of  the  sheath  and  the  forearm 
was  used  exclusively  in  my  early  cases  before  I  began  to 
use  the  transverse  drainage  under  the  tendons,  and,  while 


TEXOSVXOVITIS  OF  FIXGER  AXD  ULXAR  BURSA    259 

fairly  satisfactory,  it  in  no  way  compares  with  the  trans- 
verse drainage  in  ordinary  cases.  Its  use  should  be 
restricted  to  exceptional  cases. 

Concerning  drainage  in  these  wounds,  it  has  been 
my  experience  that  when  incision  has  been  made  in  this 
manner  no  drainage  material  is  necessary  in  the  majority 
of  cases.  If  it  is  desired  and  there  is  no  hemorrhage,  I 
insert  strips  of  rubber  dam,  while  if  there  is  hemorrhage, 
small  strips  of  gauze  thoroughly  saturated  with  vaseline 
are  packed  into  the  wound. 

It  seems  especially  unsurgical  to  draw  rubber  tubes 
or  gauze  under  the  anterior  annular  ligament,  and  I 
would  urge  strongly  that  their  use  should  be  avoided. 
The  drainage  is  not  improved  and  pressure  necrosis  is 
favored.  Moreover,  where  drainage  at  the  wrist  is 
unsatisfactory,  I  have  had  little  cause  to  be  displeased 
with  the  splitting  of  the  anterior  annular  ligament.  No 
case  has  been  seen  in  which  I  felt  that  that  procedure  per  se 
had  resulted  in  loss  of  function,  and  I  have  frequently 
seen  entire  restoration  of  function  after  it  had  been  cut. 

Treatment  of  Extensions  from  the  Little  Finger 
AND  THE  Ulnar  Bursa. — ^The  treatment  of  the  various 
extensions  in  the  finger  proper  is  the  same  as  that  outlined 
while  discussing  the  index  finger.  When  we  come  to  the 
base  we  may  have  extension  either  into  the  ulnar  bursa, 
the  lumbrical  space,  or  both.  In  the  more  acute  cases  the 
former  alone  is  most  common,  while  in  the  more  chronic 
type  it  is  often  both.  Here  the  incision  opening  the 
tendon  sheath  can  be  made  to  drain  the  lumbrical  space. 

Extensions  into  the  middle  palmar  space  are  opened 
by  following  along  the  lumbrical  space  as  in  the  other 
fingers  if  the  ulnar  bursa  is  uninvolved.  If  this  latter 
is  invaded,  the  same  incision  which  opens  the  ulnar  bursa 
may  be  utilized  by  inserting  the  forceps  through  the 
synovial  wall  of  the  bursa  under  the  tendons  into  this- 
space.     If  the  pus  has  extended  over  to  the  thenar  space, 


260    TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

it  should  be  drained  by  making  the  incision  upon  the 
dorsum  between  the  metacarpal  bones  of  the  thumb  and 
index  finger  and  opening  it  by  the  forceps,  as  was  described 
above  when  discussing  the  extensions  from  the  index 
finger. 

The  treatment  of  involvement  of  the  wrist-joint  will 
be  discussed  in  detail  in  Chapters  XXVIII  and  XXIX, 
dealing  with  chronic  processes  and  complications. 

Beginning  invasion  of  the  forearm  has  already  been 
touched  upon.  Those  patients  presenting  marked  in- 
volvement of  the  forearm  are  best  treated  by  incisions  as 
follows  (Figs.  133  and  136). 

First,  incision  upon  ulnar  side  just  above  the  wrist, 
allowing  drainage  of  the  subtendinous  space  under  the 
profundus  digitorum,  as  described  above.  Pass  an  artery 
forceps  from  the  ulnar  incision  across  the  flexor  surface 
of  the  ulna  and  radius,  cut  down  upon  its  point  on  the 
radial  side  and  enlarge  the  incision.  These  incisions 
should  be  increased  to  two  or  three  inches  in  length  if  the 
accumulation  of  pus  is  large.  This  is  especially  true  of 
the  ulnar  side,  where  even  longer  incisions  can  be  made 
with  advantage.  If  the  pus  has  involved  the  inter- 
muscular septa  higher  up,  the  incision  should  be  made 
about  half-way  up  the  forearm  upon  the  ulnar  side,  either 
just  above  the  level  of  the  ulnar  bone  or  about  an  inch 
farther  up  on  the  flexor  surface,  the  desire  being  in  the 
first  instance  to  go  between  the  flexor  carpi  ulnaris  and  the 
ulna.  Here  the  muscle  must  be  separated  from  the  bone. 
In  the  second  instance  we  atternpt  to  go  between  the 
muscular  body  of  the  flexor  carpi  ulnaris  and  the  inner 
border  of  the  flexor  sublimis  digitorum.  This  latter 
incision  gives  better  drainage,  but  there  is  some  danger 
of  injuring  the  ulnar  artery  either  primarily  or  secondarily. 
The  incision  between  the  ulna  and  the  flexor  carpi  ulnaris 
is  safer  and  is  sufficiently  satisfactory  to  give  good  results 
in  a  majority  of  cases.     This  incision  may  be  extended 


INFLAMMATION  OF  TENDON  SHEATH  OF  THUMB      201 

three  or  four  inches  £ind  generally  is  all  that  is  necessary 
in  these  cases.  The  incisions  through  the  flexor  surface 
upon  the  middle  or  radial  side  should  be  condemned. 
Particularly  in  those  lying  upon  the  middle,  i.  e.,  going 
through  the  flexor  sublimis  digitorum,  the  inflammatory 
swelling  of  the  muscular  mass  acts  as  an  effective  barrier 
to  free  drainage.  I  have  yet  to  see  the  case  in  which  the 
ulnar  incision  supplemented  by  the  two  incisions,  as 
described,  failed  to  give  free  and  satisfactory  drainage. 
(For  a  complete  discussion  of  forearm  involvement  and 
treatment  see  Chapters  XXVII  and  XXVIII.) 

At  times  it  may  be  necessary  to  make  some  incisions 
through  the  skin  for  the  liberation  of  subcutaneous 
accumulations  of  pus,  probably  lymphatic  in  origin.  The 
most  common  site  for  this  is  immediately  above  the  wrist 
on  the  flexor  surface. 

Secondary  hemorrhage  is  nearly  always  from  the  ulnar 
artery.  It  will  generally  be  advisable  to  ligate  this  after 
verifying  the  fact  that  it  is  the  vessel  at  fault,  since 
repeated  hemorrhages  are  likely  to  occur  if  tamponade  is 
depended  upon,  and  the  patients  are  generally'  not  in 
condition  to  withstand  many  hemorrhages.  (For  a 
complete  discussion  of  this  subject  see  Chapters  XXVII 
and  XXVIII.) 

When  the  radial  bursa  becomes  involved  secondarily 
to  the  ulnar  bursa,  it  should  be  treated  as  a  primar}^  radial 
bursa  infection,  which  we  will  discuss  below.  Primary 
dressing  and  after-treatment  are  discussed  later. 

Treatment  of  Inflammation  of  the  Tendon  Sheath  of  the  Long 
Flexor  of  the  Thumb. 

Here  it  is  my  habit  to  dissect  down  to  the  tendon 
upon  the  flexor  surface  of  the  proximal  phalanx;  after 
entering  the  sheath,  the  incision  is  enlarged  along  the  sac 
through  the  thenar  eminence,  separating  the  muscular 
mass  (heads  of  the  flexor  brevis  pollicis).     It  should  be 


262    TREATMEiXT  OF  SUPPURATIVE  TENOSYNOVITIS 

remembered  that  the  tendon  Hes  nearer  the  palm  than  one 
would  be  inclined  to  think,  and  that  the  mass  of  the  thenar 
muscles  lies  to  the  radial  side  of  the  incision.  This  is 
only  carried  up  to  within  a  thumb's  breadth  of  the  lower 
border  of  the  anterior  annular  ligament.  I  limit  the 
incision  at  this  point,  since  with  the  assistance  of  Professor 
P.  T.  Burns  and  Dr.  A.  T.  Horn,  at  the  Anatomical 
Laboratory  of  the  Northwestern  University  Medical 
School,  I  made  a  careful  examination  of  85  cadaver  hands, 
with  the  result  that  it  was  shoY^n  that  the  motor  nerve 
to  the  thenar  muscles  passes  across  the  sheath  between 
this  point  and  the  lower  edge  of  the  anterior  annular 
ligament,  and  in  my  opinion  loss  of  the  flexor  longus 
pollicis  tendon  is  to  be  preferred  to  destroying  this  nerve 
and  thus  bringing  about  a  loss  of  the  muscles  which  it 
supplies.  Drainage  of  the  upper  end  of  the  radial  bursa 
is  best  carried  out  by  the  methods  described  above  when 
discussing  drainage  of  the  upper  end  of  the  ulnar  bursa. 
Incisions  are  made  laterally  at  the  flexor  surface  of  the 
ulna  and  radius  and  through-and-through  drainage 
secured  under  the  flexor  profundus  tendons.  At  times 
incision  upon  the  radial  side  alone  will  be  sufficient  if  the 
sheath  has  not  already  ruptured.  If  it  has  not  ruptured, 
two  fingers  are  thrust  into  the  radial  incision  under  the 
tendons  and  a  grooved  director  or  forceps  is  pushed  up 
from  the  palmar  incision  along  the  sheath.  The  end 
of  the  forceps  is  easily  felt  in  the  forearm  under  the 
tendons.  The  sheath  is  opened  and  gauze  saturated  with 
vaseline  or  rubber-dam  strips  inserted  into  the  wound  for 
drainage.  (For  a  further  study  of  the  basis  upon  which 
this  method  is  advised  see  Chapters  XXVII  and  XXVIII.) 
At  times  an  accumulation  of  pus  will  be  found  on  the 
forearm  subcutaneously  just  above  the  wrist  upon  the 
radial  side.  When  this  is  opened  the  surgeon  may  be  of 
the  opinion  that  the  sheath  has  ruptured  and  is  thus 
draining  anteriorly;  hence,  he  will  desist  from  drainage  of 


INFLAMMATION  OP  TENDON  SlIIPATII  OP  THUMB     20^ 

the  deeper  tissue.  Such  an  accumulation  is  of  lymphatic 
origin  and  has  no  connection  with  the  sheath,  so  that  the 
lateral  incisions  described  above  should  always  be  made  in 
addition  to  this  skin  incision  in  front. 

At  times,  owing  to  necrosis  of  tendons  or  extensive 
suppuration  among  them,  it  may  be  advisable  to  drain 
the  sheath  from  the  front,  in  which  case  an  incision  is 
made  going  a  quarter  of  an  inch  to  the  radial  side  of  the 
median  line  of  the  flexor  surface  of  the  forearm.  The 
dissection  is  carried  down  to  the  radial  side  of  the  flexor 
sublimis  tendons,  avoiding  the  median  nerve  which  lies 
in  the  floor  and  to  the  ulnar  side.  The  tendon  sheath 
has  generally  ruptured  by  this  time,  or  can  be  identified 
by  a  grooved  director  or  fine  probe  passed  from  the  opened 
sheath  below.  It  is  entirely  safe  to  cut  the  upper  part  of 
the  anterior  annular  ligament  (Fig.  95), 

In  almost  every  case,  however,  I  feel  that  this  anterior 
incision  should  be  limited  to  opening  the  subcutaneous 
accumulation  if  there  be  any,  and  the  tendon  sheatl^should 
be  opened  by  the  lateral  incisions  described  atrove  for 
entering  the  space  between  the  flexor  profundus  tendons 
and  the  pronator  quadratus.  Good-sized  incisions  should 
be  made,  so  that  drainage  may  be  free. 

In  many  cases  where  the  infection  has  been  severe  or 
the  tendon  impaired  primary  removal  of  the  tendon  should 
be  favored.  This  is  particularly  liable  to  die  and  remain 
for  many  weeks,  causing  the  infection  to  persist  and 
jeopardize  other  structures,  so  that  if  the  tendon  is  at  all 
destroyed  or  the  infection  shows  a  slow  recovery  it  should 
be  removed  at  once. 

The  principles  of  treatment  of  involvement  of  the 
thenar  space  and  the  ulnar  bursa  have  already  been 
discussed.  In  relation  to  secondary  ulnar-sheath  infection, 
it  may  be  noted  that  there  is  doubt  frequently  as  to  the 
diagnosis  in  these  cases.  In  such  cases  it  is  advisable 
to  dissect  down  carefully  upon  the  sheath  in  the  lower 


264    TREATMENT  OF  SUPPURATIVE  TENOSYXOVITIS 

third  of  the  palm  just  to  the  radial  side  of  the  hypothenar 
space.  After  the  palmar  fascia  is  cut,  a  \yc\(\  of  edematous 
fat  will  be  seen  to  bulge  into  the  wound  as  if  there  were 
great  tension  in  the  subaponeurotic  palmar  space.  This 
fat  having  been  dissected  away,  the  tense  bursa  will  be 
seen  to  bulge  into  the  field.  This  is  opened  and  the 
operation  proceeds  as  described  above  while  discussing  the 
technique  of  treatment  of  the  ulnar  bursa.  There  is 
always  a  grave  decision  to  make  as  to  whether  or  not  the 
sheath  of  the  little  finger  tendon  has  become  involved, 
and  therefore  should  also  be  opened.  Involvement  of  the 
carpal  joints  is  discussed  in  Chapter  XXVII. 

When  the  forearm  becomes  involved,  the  treatment  is 
the  same  as  when  the  involvement  has  originated  from 
the  ulnar  bursa,  since  the  foci  of  extension  are  the  same. 

The  case  of  Mr.  W.  is  reported,  since  it  is  probably  the 
most  virulent  case  of  tenosynovitis  beginning  in  the 
thumb  and  extending  over  by  way  of  the  tendon  sheath 
of  the  flexor  longus  pollicis  to  the  ulnar  bursa  that  I  have 
had  an  opportunity  to  observe.  The  infection  was  viru- 
lent and  the  toxic  symptoms  so  severe  as  to  threaten  the 
patient's  life.  The  result  was  very  satisfactory  con- 
sidering the  fact  that  the  case  did  not  come  under  observa- 
tion until  after  the  sheath  had  been  involved  for  at  least 
thirty-six  hours.  In  this  case  there  was  a  complete 
restoration  of  function  of  the  entire  hand  and  fingers, 
with  the  possible  exception  of  slight  loss  of  flexion  of  the 
distal  phalanx  of  the  little  finger.  This  result  is  a  marked 
contrast  to  those  cases  of  similar  nature  which  I  have  seen 
several  days  after  the  sheath  had  become  involved,  when 
such  destruction  of  the  tendons  and  their  coverings  had 
taken  place  as  to  preclude  the  possibility  of  a  favorable 
outcome  no  matter  what  the  surgical  procedure  might  be. 
The  history  of  the  case  is  practically  identical  with  one 
seen  two  months  previously,  which  had  remained  eight 
days  without  opening.     The  general  health  and  resistance 


INFLAMMATION  OF  TENDON  SHEATH  OF  THUMB    205 

4 

of  the  individuals  were  much  the  vsame.  The  outcome  in 
the  first  case  which  had  been  treated  conservatively  was 
most  disastrous,  the  patient  barely  escaping  with  his  life 
and  ending  with  a  functionless  hand.  After  observing 
these  two  cases,  so  close  together  and  many  others  both 
before  and  since  with  such  similar  conditions,  I  cannot  but 
feel  that  under  these  conditions  conservatism  is  most 
inadvisable,  and  that  the  earliest  possible  opening  of  the 
sheath  is  indicated. 

Case  XIII. — Mr.  W.,  referred  by  Dr.  Colleran,  Post- 
Graduate  Hospital,  July,  1908  (Fig.  99). 

Patient  gave  a  history  of  having  run  a  splinter  of  wood  into 
the  distal  phalanx  of  the  thumb  seven  days  previous  to  coming 
to  the  clinic.  This  had  been  removed  with  a  penknife,  and 
later,  at  the  end  of  five  days,  another  splinter  had  been 
removed.  Three  days  before,  he  began  to  complain  of  pain 
over  the  course  of  the  thumb  and  radial  side  of  the  hand.  The 
whole  hand  now  became  tender  and  swollen. 

On  examination,  temperature  was  101°;  pulse,  96.  The 
whole  hand  was  found  to  be  swollen  on  both  the  flexor  and 
dorsal  surfaces,  as  was  also  the  forearm.  Concavity  of  the 
palm  was  still  present.  Tenderness  was  most  marked  at  the 
wrist-joint  and  slightly  above  on  both  the  radial  and  ulnar 
sides.  There  was  tenderness  also  along  the  course  of  the  ulnar 
bursa  in  the  palm  of  the  hand  and  over  the  tendon  sheath  of 
the  little  finger.  There  was  only  slight  tenderness  in  the  palm 
of  the  hand.  Tenderness  was  also  found  over  the  course  of  the 
flexor  longus  pollicis.  There  is  no  tenderness  over  the  index, 
middle,  or  ring  fingers,  and  none  on  the  dorsum.  On  extension 
of  the  fingers,  extension  of  the  little  finger  and  thumb  caused 
marked  pain,  the  ring  finger  slight  pain,  and  the  middle  and 
index  fingers  very  little  pain. 

Diagnosis  of  tenosynovitis  of  the  flexor  longus  pollicis,  the 
intermediary  sheaths  at  the  wrist,  and  the  ulnar  bursa  was 
made. 

Operation. — General  anesthesia;  Esmarch's  bandage  applied. 
Incision  was  made  through  the  skin  and  subcutaneous  tissue 
over  the  ulnar  bursa  in  the  lower  third  of  the  palm.  After 
cutting  through  the  palmar  fascia  the  fat  bulged  into  the 
wound.     This  was    split   and    the  bulging  sheath  was  seen 


266    TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

beneath.  This  was  opened  and  pus  found.  The  sheath  was 
then  opened  throughout  its  length  from  the  base  of  the  middle 
finger  up  to  and  through  the  anterior  annular  ligament 
(Fig.  99).  Pus  was  found  throughout.  An  incision  was  then 
made  in  the  forearm  on  either  side  at  the  level  of  the  flexor 
surfaces  of  the  ulna  and  radius,  one  inch  above  the  anterior 
annular. ligament;  an  artery  forceps  was  passed  underneath 
the  tendons  of  the  flexor  profundus  digitorum.  A  slight 
amount  of  pus  was  found  here.    An  artery  forceps  now  opened 


Fig.  99. — Photograph  showing  the  incision  in  the  case  of  Mr.  W.,  splitting 
of  the  ulnar  bursa  and  radial  bursa  and  incisions  above  the  wrist.  Accompany- 
ing photographs  show  result  two  and  one-half  months  after  treatment.  (See 
Case  XIII.) 


the  sheath  of  the  ulnar  bursa  at  its  upper  end,  passing  into 
the  space  underneath  the  flexor  tendons,  and  a  finger  enlarged 
the  opening. 

An  incision  was  made  over  the  proximal  end  of  the  proximal 
phalanx  of  the  thumb  into  the  sheath  of  the  flexor  longus 
pollicis.  A  small  amount  of  slightly  turbid  fluid  was  present 
that  was  not  clearly  pus.  The  opening  was  extended,  however, 
to  the  distal  end,  where  considerable  pus  was  evacuated. 
The  incision  was  then  extended  upward  along  the  sheath  to 
within  a  thumb's  breadth  of  the  lower  border  of  the  anterior 


INFLAMMATION  OF  TENDON  SHEATH  OF  THUMB    207 

annular  ligament.  Free  pus  was  found  here  also.  An  artery 
forceps  was  then  passed  along  the  sheath  up  into  the  forearm 
underneath  the  flexor  profundus  tendons,  communicating 
with  the  opening  previously  made. 


Fig.  lOO.^^Photograph  showing  the  dorsal  right-angled  splint  used  after  splitting 
the  annular  ligament  in  infection  of  the  ulnar  bursa.  In  the  photograph  the 
hand  has  been  loosened  from  the  dressing  so  as  to  show  the  right-angled  splint. 

After  washing  the  sheath  out  thoroughly  with  normal  salt 
solution,  strips  of  gauze  saturated  with  vaseline  were  laid 
between  the  cut  edges  of  the  skin  in  the  palm  and  also  drawn 
transversely  underneath  the  flexor  profundus  through  the 
forearm  incisions.     Hot  boric  dressings  were  applied. 


268    TREATMENT  OF  SUPPURATIVE  TEXOSYXOVITIS 

Subsequent  Course. — Pain  was  immediately  relieved,  tem- 
perature fell  to  99°,  around  which  it  remained,  at  no  time 
going  higher  than  ioo°,  and  the  patient  made  a  gradual  and 
satisfactory  recovery.  At  the  end  of  twenty-four  hours  the 
hot  boric  acid  dressings  were  changed  for  dry  dressings,  the 
inner  layer  of  which  was  saturated  with  vaseline.  The  strips 
of  gauze  between  the  edges  of  the  wound  were  removed,  the 
hand  was  dressed  in  dorsal  extension  on  a  right-angled  dorsal 
splint  (Fig.  lOO). 

Subsequent  Treatment. — Each  day  the  hand  was  dressed, 
each  of  the  articulations  was  moved,  including  the  finger- 
joints  and  wrist,  and  the  hand  dressed  in  dorsal  extension. 
On  the  fifteenth  day  it  was  deemed  advisable  to  open  the 
tendon  sheath  of  the  little  finger,  which  had  not  been  opened 
at  the  time  of  operation.  A  small  amount  of  pus  was  evacu- 
ated, and  I  believe  it  would  have  been  ad\isable  to  have 
opened  this  sheath  at  the  time  of  the  primary  operation. 
The  incisions  over  the  flexor  longus  pollicis  were  completely 
healed  at  the  end  of  three  and  one-half  weeks.  Those  above 
the  wrist  closed  at  the  end  of  five  days.  That  over  the  tendons 
of  the  ulnar  bursa  was  completely  closed  at  the  end  of  four 
and  one-half  weeks.  All  that  time  the  patient  could  move 
slightly  all  the  fingers  of  the  hand,  and  flex  voluntarily,  with 
the  exception  of  the  little  finger,  every  joint,  including  the 
wrist.  He  was  urged  to  use  his  hand  repeatedly  and  to 
return  for  passive  motions.  In  this  respect  he  was  somewhat 
dilatory.  At  the  beginning  of  the  sixth  week  his  hand  was 
treated  daily  in  theKlapp  apparatus  for  breaking  up  adhesions, 
and  at  the  end  of  the  ninth  week  he  began  to  work  with  his 
hand,  and  at  the  end  of  the  twelfth  week  he  had  practically 
complete  function  of  all  joints  and  fingers,  with  the  exception 
of  the  little  finger,  where  there  was  only  25  per  cent,  of  func- 
tion.    This  will  improve,  but  will  never  be  perfect  (Fig.  99). 

Later  experience  has  taught  me  that  active  movements 
of  the  fingers  should  have  been  begun  at  once  following 
the  incision. 

The  follow^ing  case  of  acute  streptococcic  infection 
of  the  flexor  longus  pollicis  is  reported  in  some  detail, 
since  it  is  one  in  which  the  patient  narrowly  escaped 
with  her  life,  and  shows  the  course  in  these  cases;  and 


INFLAMMATION  OF  TENDON  SHEATH  OF  THUMB    269 

because  the  sheath  ruptured  permitting  involvement  of 
the  subprofundus  space  without  involvement  of  the 
ulnar  bursa. 

The  complete  restoration  of  the  tendon  function  in 
this  case  is  most  encouraging.  I  believe  that  with  an 
early  incision,  carefull}^  followed  by  conservative  treat- 
ment, we  can  hope  for  much  better  results  in  the  future 
than  in  the  past. 

Case  XIV. — Dr.  S.,  seen  in  consultation  with  Dr.  Besley, 
gave  the  following  history  which  is  abbreviated  from  the 
history  sheets  of  the  hospital: 

January  23.  Pulse,  100;  temperature,  101.8°;  respirations, 
26.  Hot  dressings  applied  to  right  arm;  under  nitrous  oxide 
anesthesia,  Dr.  M.  L.  Harris  incised  the  flexor  surface  of  the 
thumb.     Condition  good. 

January  24.  Pulse,  80;  temperature,  98.6°;  respirations, 
20.    Slept  fairly  well.    Condition  seems  very  much  improved. 

January  26.     Leukocytosis,  11,000. 

January  27.  Pulse,  64;  temperature,  98°;  respirations, 
20.  Entire  thurrib  swollen  and  pus  oozes  from  incisions. 
Thumb  again  incised  by  Dr.  Charles  Davison;  drainage 
inserted.  Normal  salt  enemas  given  every  four  hours;  hot 
boric  acid  solution  to  part;  5  p.m.,  pulse,  80;  temperature, 
101°;  respirations,  20. 

January  29,  4  a.m.  Pulse,  108;  temperature,  102.8°; 
respirations,  26;  8  a.m.,  pulse,  80;  temperature,  103.4°;  respir- 
ations, 22;  leukocytosis,  21,000.  Thumb  irrigated  with  hot 
boric  and  peroxide;  dry  dressings  applied;  9  p.m.,  temperature, 
102.2°;  palm  of  hand  greatly  swollen  and  angry  red  extending 
into  wrist.     Vomited  small  amount  of  fluid. 

January  30,  9  a.m.  Temperature,  101.6°;  nauseated  and 
vomited  greenish  fluid;  face  flushed;  slept  very  little. 

January  31,  9  a.m.  Temperature,  101.4°;  pulse,  96;  respir- 
ations, 20.  Swelling  on  hand  increasing  and  extending;  under 
gas-ether  anesthesia  Dr.  F.  A.  Besley  made  an  incision  Into 
the  radial  bursa,  liberating  yellowish  pus.  Rubber  drain 
inserted,  allowing  free  drainage  between  first  and  second 
metacarpals.  Small  Incision  made  above  wrist,  but  no  pus 
found  In  arm,  although  there  was  considerable  redness  and 
swelling. 


270    TREATMEXT  OF  SUPPURATIVE  TENOSYNOVITIS 

February  i.  Pulse,  84;  temperature,  102°;  respirations, 
20.  Slept  some  since  10  p.m.  Pain  in  hand.  Hot  dressings. 
Smears  from  pus  show  short  chains  of  streptococci. 

February  2.  Temperature,  101.6°;  leukocytosis,  24,000. 
Feels  rather  drowsy.  Does  not  have  much  pain.  Slept  at 
intervals. 

February  3.  Pulse,  84;  temperature,  100.2°;  respirations, 
20.  Cultures  on  agar  and  in  bouillon  show  only  streptococci; 
leukocytosis,  32,000.  Under  gas  anesthesia  incisions  enlarged 
and  opened  wide  by  forceps  by  Drs.  Besley  and  Kanavel. 

February  4,  i  a.m.  Pulse,  80;  temperature,  102°;  9  p.m., 
temperature,  101°.     Slept  most  of  forenoon. 


Fig.  101. — Photograph  showing  the  function  present  in  Case  XIV:  infection  of 
the  radial  bursa,  three  months  after  treatment. 


February  5,  10  a.m.  Temperature,  102°.  Hand  dressed. 
Swelling,  hyperemia,  and  tenderness  along  flexor  surface  of 
arm,  radial  side.  Pus  oozes  from  wounds.  Good  night's 
rest;  4  p.m.,  pulse,  112;  temperature,  103°;  respirations,  24. 
Another  incision  made  in  forearm  by  Dr.  Besley.  The 
incision  was  made  on  radial  surface  of  arm,  and  liberated  a 
large  quantity  of  yellow  pus.  Gauze  packing  inserted.  Gas 
anesthesia.  7.30  p.m.,  gauze  packing  removed.  Patient 
rather  restless. 

February  6.     Pulse,  92 ;  temperature,  102  ° ;  respirations,  20. 

February  7.  Pulse,  90;  temperature,  99.4°;  respirations, 
20.  Patient  very  comfortable.  Small  superficial  pocket  of 
pus  on  anterior  surface  of  wrist  opened  by  Dr.  Besley. 


SYNOVIAL   SHEATHS  OX   THE  DORSUM 


271 


February  8.     Pulse,  80;  temperature,  98°;  respirations,  20. 

From  this  time  on  the  temperature  remained  normal. 
Patient  gradually  improved,  and  was  discharged  February  24. 
The  wound  in  the  thenar  space  closed  al)out  two  weeks  later. 

Subsequent  History. — At  the  end  of  hve  months  the  case 
presents  a  complete  restoration  of  function  of  the  muscles 
of  the  thumb  and  the  tendon  of  the  flexor  longus  pollicis,  and 
the  tendons  of  the  hand  upon  flexion  (Fig.  lOi). 


Fig.  102.-Tr^'Acute  suppurative  dorsal  tenosynovitis.  Note  the  area  of  sur- 
rounding edema.  The  tendon  sheath  "is.  only  about  one-half  the  length  of  the 
tumefaction. 


Synovial  Sheaths  on  the  Dorsum. 

When  the  synovial  sheaths  upon  the  dorsum  are 
infected,  a  simple  splitting  of  the  sheath  throughout  its 
length  apparently  gives  the  best  results  (Fig.  102).    I  have 


272    TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

had  only  four  of  these  cases  due  to  acute  infection,  and 
they  all  recovered  with  good  function  after  a  short  time, 
with  the  exception  of  the  case  in  which  this  involvement 
was  associated  with  a  palmar  infection,  when  a  fatal  issue 
followed  (Case  XXII). 

AFTER-TREATMENT. 

Drainage. — The  use  of  drainage  has  been  discussed 
by  every  surgeon,  and  the  principles  underlying  it  here 
are  the  same  as  elsewhere.  Those  who  after  much 
experience  and  thought  have  decided  upon  its  use  will 
probably  use  it  here.  My  own  results  have  led  me  to 
abandon  it  almost  entirely.  I  never  use  a  rubber  tube, 
owing  to  my  fear  of  pressure  necrosis.  Gauze,  if  left  in 
many  hours,  begins  to  act  as  a  plug.  Unless  there  is 
bleeding,  it  is  not  used.  If,  however,  one  fears  that  the 
skin  will  close  down  at  once  and  prevent  the  escape  of  pus, 
strips  of  rubber-dam  made  from  an  old  rubber  glove  are 
inserted,  but  if  there  is  much  venous  oozing  gauze  satu- 
rated with  vaseline  is  used.  I  have  found  this  to  give 
good  drainage  and  not  to  act  so  much  as  a  plug,  yet  giving 
tampon  pressure  in  cases  of  oozing.  Strips  may  be 
inserted  from  the  sides  above  the  wrist  under  the  flexor 
profundus,  and  also  above  into  the  ulnar  incision  on  the 
forearm.  I  have  also  used  gutta-percha  strips  with 
satisfaction.  In  my  earlier  cases  drainage  tubes  were 
inserted  through  from  the  palm  to  the  dorsum,  after  the 
older  methods  of  palmar  drainage,  but  since  introducing 
palmar  drainage  along  the  lumbrical  spaces  this  procedure 
has  been  abandoned  entirely. 

In  the  virulent  cases,  every  attempt  is  made  not  to 
manipulate  the  arm  and  hand  any  more  than  is  necessary, 
so  as  to  protect  the  patient  against  absorption  of  toxins 
as  much  as  possible.  The  application  of  the  Bier  method 
of  constriction  of  the  arm  to  prevent  the  rapid  absorption 
of  bacteria  and  toxins  during  and  immediately  after  incis- 


AFTER-TREAT  SLENT  273 

ion  has  alreach'  been  touched  upon.  Durini^  the  after- 
treatment  the  same  i^recautions  are  taken  so  lonj^  as  the 
process  is  acute.  The  arm  is  kept  immobihzed  and 
slight!}-  elevated.  This  latter  is  done  to  secure  comfort 
as  much  as  to  aid  in  recover}-.  The  von  Volkmann 
treatment.  /.  c,  ^-ertical  elevation  of  the  hand,  has  not 
seemed  to  me  to  be  of  great  therapeutic  value,  although 
apparentl}-  it  is  a  valuable  procedure  in  that  it  prevents 
excessive  edema  in  the  later  stages. 

For  the  first  few  da^-s  after  incision  it  would  appear 
that  hot,  moist  dressings  are  of  value  to  relieve  the  pain 
and  promote  walling  off  of  the  infection.  After  this 
stage  they  should  be  abandoned  in  favor  of  dry  dressings, 
since  the}-  seem  to  produce  excessive  granulation.  In 
most  cases  I  have  been  able  to  apply  dry  dressings  at  the 
end  of  twenty-four  hours.  The  hot,  moist  dressings  are 
generally  made  from  a  saturated  solution  of  boric  acid. 
However,  it  is  probable  that  the  moist  heat  is  the  essential 
factor.  Strong  antiseptic  solutions,  such  as  bichloride 
and  carbolic  acid,  are  never  used.  The  inner  layer  of  the 
dry  gauze  may  be  saturated  with  vaseline  to  prevent  it 
adhering  to  the  wound.  As  soon  as  the  moist  hot  dress- 
ings are  discontinued  I  bake  the  hand  under  the  exposure 
of  an  electric  light  three  to  four  hours  each  day  and  apply 
only  one  or  two  thicknesses  of  gauze  as  a  dressing. 

The  hand  is  dressed  from  once  to  twice  daily.  If 
gauze  has  been  inserted  and  has  adhered  to  the  wound, 
there  is  less  shock  produced  by  anesthetizing  the  patient 
with  a  small  amount  of  nitrous  oxide  than  is  given  b}-  the 
pain  incident  to  withdrawal  without  such  an  aid. 

The  hand  is  dressed  with  the  fingers  in  extension  upon 
the  dorsal  splint  for  a  part  of  the  day.  This  is  done  to 
prevent  prolapse  of  the  tendons  and  atrophy  of  the 
muscles  in  contraction.  In  the  fingers  this  procedure  is 
of  special  importance,  not  onl}-  to  avoid  the  prolapse  of 
the  tendons,  but  also  to  prevent  all  of  the  fingers  tending 
to  become  flexed  in  one  position. 

i8 


274    TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

I  ordinarily  mould  a  plaster-of-Paris  splint  to  fit  the 
back  of  the  forearm  up  to  the  wrist;  here  the  plaster  splint 
is  bent  back  at  a  right  angle.  The  hardened  splint  is 
applied  to  the  forearm  and  held  in  place  by  a  bandage. 
A  second  bandage  now  attempts  to  bring  the  hand  back 
to  the  horizontal  prolongation.     At  times  I   have  used 


Fig.  103. — Photograph  of  result  one  month  after  incision  and  active  early 
treatment  of  an  infection  of  ulnar  and  radial  bursae  with  extension  of  pus  into 
forearm.  Incision  five  days  after  the  infection  had  fully  developed.  Amputation 
had  been  advised  by  his  physician. 

light  elastic  pressure.  The  tension  and  position  are  varied 
from  day  to  day  after  danger  of  prolapse  has  ended,  so  as 
to  prevent  ankylosis  of  the  tendons  and  joint  in  one 
position.  The  primary  splint  is  applied  immediately  after 
the  operation  (Fig.  lOo). 

The  prevention  of  adhesions  in  the  joints,  preservation 
of  the  vitality  of  the  muscles,  and  the  use  of  the  tendons 


AFTER-TREATMEXT  275 

is  most  important,  and  at  times  the  results  are  dis- 
couraging-. I'nfortunately  the  surgeon  so  often  sees  these 
cases  after  primary  incisions  have  been  made  and  the  case 
treated  for  several  days.  In  the  severe  fulminating  types 
this  has  permitted  such  destruction  of  the  tendons  and 
syno\'ial  coverings  as  to  make  any  after-treatment  of 
little  avail.  It  seems  to  me  advisable  to  begin  passive 
and  active  movements  ivitkin  a  short  time  after  primary 
incisions;  in  other  words,  as  soon  as  the  danger  of  systemic 
infection  is  over,  ordinarily  inside  of  forty-eight  hours 
after  the  primary  incision.  I  do  not  believe  that  the 
local  condition  is  made  materially  worse,  and  we  do  aid 
in  the  prevention  of  firm  adhesions.  It  is  better  to  do 
this  in  baths  of  very  hot  water,  which  relieves  the  pain 
to  some  extent  and  helps  to  cleanse  the  discharging  wound. 
The  patient's  hand  and  forearm  being  immersed  in  hot 
sterile  water,  the  surgeon  with  glove-covered  hands 
gently  flexes  and  extends  each  finger,  as  well  as  the  hand 
at  the  wrist,  several  times.  Violent  movements  are  not 
indulged  in.  The  bath  is  not  kept  up  any  length  of  time, 
since  we  wish  to  prevent  rather  than  to  favor  the  develop- 
ment of  granulation  tissue  at  this  stage.  The  patient  is 
encouraged  to  make  active  movements  himself.  If  a  dry, 
hot  chamber  is  at  hand,  this  may  be  used  to  advantage. 
/  cannot  emphasize  too  strongly  the  importance  of  this  early, 
gentle,  and  intelligent  manipulation.  I  do  not  refer  to 
massage,  but  to  the  intelligent  use  of  the  various  joints, 
muscles,  and  tendons. 

A  complete  discussion  of  reconstructive  treatment  in 
these  patients  will  be  found  in  Chapter  XXX. 


CHAPTER    XVII. 

THE  TREATMENT  OF  FASCIAL-SPACE 
ABSCESS. 

We  shall  here  consider  the  treatment  of  fascial  space 
abscesses  uncomplicated  by  tenosynovitis,  or  in  case  of 
complications  presenting  only  those  of  minor  importance, 
so  that  the  fascial-space  abscess  is  still  the  predominant 
picture. 

The  treatment  naturally  divides  itself  into  prophylactic 
and  active.  In  the  first  instance  all  wounds  should  be 
given  aseptic  care,  and  any  localized  infection  should  be 
attended  to,  thorough  drainage  being  instituted  before 
the  infection  has  a  chance  to  spread.  This  however  is 
not  a  plea  for  incision  "as  a  prophylactic  precaution"  or 
in  the  absence  of  a  definite  diagnosis  of  an  accumulation 
of  pus.  Whenever  the  surgeon  makes  an  incision  and 
evacuates  only  serum  he  has  harmed  the  patient.  In 
those  cases  in  which  we  are  waiting  to  decide  whether  or 
not  a  localized  abscess  is  present,  immobilization  and  the 
local  use  of  the  well-known  hot,  moist  dressing  is  probably 
more  efficient  than  any  other  application.  Conservatism 
is  more  justifiable  here  than  in  tendon-sheath  infection — 
and  again  let  me  emphasize  that  pus  is  seldom  found  on 
the  dorsum  of  the  hand.  The  usual  general  tonic  and 
excretory  procedures  should  be  instituted. 

Should  the  diagnosis  of  a  localized  accumulation  of 
pus  in  any  of  the  various  tissues  be  made,  our  first  question 
is.  What  is  the  best  site  for  incision?  We  need  not  discuss 
the  fact  that  such  a  condition  as  that  demands  early  and 
efficient  drainage.  Should  the  subcutaneous  tissue  of  the 
dorsum  or  the  areas  under  the  epidermis  or  dermis  of  the 


THE  MIDDLE  PAUfAR  SPACE  277 

jialin  l)c  imoKc'd,  ov  minor  infections  of  (he  thenar  and 
h>'pothenar  areas  be  present,  a  wide  o|)eninj;  by  simple 
incision  is  generally  sufficient.  Should  the  middle  palmar, 
thenar,  lumbrical,  or  subaponeurotic  spaces  be  involved, 
however,  some  special  consideration  is  necessary. 

THE  MIDDLE  PALMAR  SPACE. 

Technique  of  Treatment. — It  is  probably  better  to 
err  upon  the  side  of  radicalism,  than  couvservatism,  when 
confronted  with  a  middle  palmar-space  abscess,  owing  to 
the  liability  of  complications  in  the  ulnar  synovial  sheath, 
the  nerves,  the  bones,  and  the  joints,  if  the  abscess  is 
neglected. 

Any  method  of  opening  the  space  exposes  certain  tissues 
to  injury,  and  it  is  a  question  of  choosing  the  least  danger- 
ous route.  It  cannot  be  opened  upon  the  ulnar  side, 
owing  to  the  fear  of  infecting  the  ulnar  bursal  sheath;  a 
flap  of  the  palmar  fascia  should  not  be  dissected  up  from 
below,  as  has  been  suggested,  making  a  sort  of  trap-door,  as 
it  were,  since  the  infection  lies  below  the  tendons,  and  to 
make  such  an  opening  and  then  drain  anteriorly  between 
the  tendons  would  result  in  unnecessary  adhesions. 

The  least  injury  and  the  most  efficient  drainage  of  the 
middle  palmar  space  can  be  secured  by  an  incision  along 
one  of  the  three  lumbrical  canals  leading  into  this  space, 
i.  e.,  the  little  finger,  ring  finger,  or  the  middle  finger  canals 
(Fig.  104).  That  canal  will  be  chosen  which  is  already 
markedly  infected,  either  because  it  has  been  the  atrium 
of  the  infection  or  because  it  has  been  secondarily  involved. 
If  the  surgeon  has  any  choice  in  the  matter,  that  between 
the  ring  and  middle  finger  gives  the  most  satisfactory 
drainage.  An  incision  is  made  into  the  canal  and  carried 
one-half  inch  above  its  end  up  into  the  palmar  space,  /.  e., 
one-half  inch  proximal  to  a  line  joining  the  proximal  end 
of  the  distal  flexion  crease  with  the  distal  end  of  the 
middle  flexion  crease,   or,   grossly  speaking,   a  thumb's 


278        TREATMENT  OF  FASCIAL  SPACE  ABSCESSES 

breadth  and  a  half  up  into  the  i)ahn.  This  brings  the 
incision  between  the  tendons.  An  artery  forceps  is 
thrust  under  the  group  of  palmar  tendons  and  the  blades 
opened,  satisfactory  drainage  ensuing.  A  small  strip 
of  rubber-dam  or  gauze  saturated  with  vaseline  will  keep 


Fig.  104. — Showing  incisions  for  opening  the  lumbrical  space  and  for  opening  the 
lumbrical  space  in  conjunction  with  the  middle  palmar  space. 

the  opening  from  closing  for  a  day,  after  which  time  it  will 
not  be  needed.  It  is  remarkable  how  rapidly  cases  w^ill 
recover  under  this  treatment. 

Herewith  is  reported  the  first  case  in  which  I  used  this 
method.  I  have  used  it  many  times  since  with  absolute 
satisfaction. 


THE  MIDDLE  PALMAR  SPACE  270 

Case  X\'. — Infection  base  of  palm  spreadinjj;  along  lum- 
brical  canal  into  palm;  incision  along  canal.  Rccoxcry  with 
perfect  function. 

]\I.  R.,  treated  at  the  Post-Graduate  Hospital,  July,  1906. 
Service  of  Prof.  F.  A.  Besley.  F'ive  days  before  entrance 
patient  developed  an  infection  from  the  crack  of  a  callus  at 
the  base  of  the  palm  of  the  right  hand  between  the  ring  and 
little  fingers.  An  abscess  had  formed  in  the  fascial  space  at 
the  base  of  these  fingers  and  extended  along  the  lumbrical 
canal.  Upon  investigation  it  was  found  to  have  in\'olved 
the  middle  palmar  space.  This  was  diagnosticated  by  the 
tenderness  localized  over  the  lumbrical  canal,  and  the  bulging 
of  the  palm  associated  with  localized  tenderness.  The  incision 
was  made  at  the  original  site  of  the  infection,  passing  from 


Fig.  105. — Photograph  of  incision  in  a  case  of  infection  in  the  middle  palmar 
space  originating  in  web  at  end  of  lumbrical  canal.  Recovery  with  complete 
function  in  ten  days.     (See  Case  XV.) 

the  palm  through  the  fascial  tissue  to  the  dorsum  between  the 
proximal  phalanges  of  the  fingers.  A  grooved  director  was 
then  inserted  along  the  lumbrical  canal,  which  was  opened 
throughout  its  extent,  the  incision  being  carried  up  to  the 
middle  flexion  crease  of  the  palm;  in  other  words,  one-half 
inch  above  the  lumbrical  canal.  Forceps  were  now  inserted 
underneath  the  tendons,  opening  the  palmar  space  widely; 
about  one  ounce  of  pus  escaped;  no  drain  was  inserted;  hot 
boric  acid  dressings  applied. 

Course. — At  the  end  of  ten  days  all  discharge  of  pus  had 
ceased  and  wound  had  healed.  At  the  end  of  three  weeks 
complete  function  was  present  in  all  the  fingers  and  hand 
(Fig.  105). 


280        TREATMENT  OF  FASCIAL  SPACE  ABSCESSES 

The  TkiiATMENT  OF  Combined  Involvement  of  the  Middle  I'almar 
AND  Thenar  Spaces. 

The  treatment  here  can  Ix;  l)est  illustrated  by  quoting 
a  typical  case.  Here  the  middle  palmar  and  the  thenar 
spaces  having  been  simultaneously  in\T)lvcd,  the  forceps 


Fig.  106. — Drawing  showing  the  drainage  under  tendons.  AT,  adductor 
transversus;  LS,  lumbrical  space;  MPS,  middle. palmar  space;  TS,  thenar  space; 
UB,  ulnar  bursa. 


was  passed  from  the  incision  into  the  middle  palmar  space 
under  the  palmar  tendons,  as  already  described,  and 
pushed  through  the  thin  septum  separating  the  palmar 
and  thenar  spaces  at  the  proximal  end,  the  ])oint  thus 
passing    through    the    thenar    space    superficial    to    the 


TREATMENT  OF  PALMAR   AM)   TIIEXAR  SPACES     2S1 

culductor  transversus  and  coming  out  on  (lie  dorsum 
l)ctA\'een  the  meteicarpal  bones  of  the  thumb  and  index 
finger  (Fig.  io6).  A  rubber-dam  drainage  strip  was  then 
drawn  through  and  left  eighteen  hours. 

Case  XVI. — Primary  infection,  cracks  from  callus  on 
palm,  extension  into  palm  of  hand,  drainage  of  middle  palmar 
space,  thenar  space,  ulnar  bursa,  and  forearm.  Recovery 
with  perfect  function. 

H.,  Post-Graduate  Hospital.  Two  weeks  before  coming 
to  the  hospital  patient  had  developed  an  infection  in  the  palm 
of  the  hand,  evidently  in  the  callus  produced  by  tongs,  while 
handling  ice.  Two  or  three  inadequate  incisions  had  been 
made  when  the  patient  entered  the  hospital,  with  a  tempera- 
ture of  102°  and  an  enormous  swelling  of  the  entire  hand  and 
forearm,  involving  the  palmar  and  dorsal  surfaces.  The 
palmar  fascia  bulged  up  instead  of  presenting  its  normal 
concavity,  while  the  thenar  area  was  ballooned  out  as  if 
inflated  to  its  complete  capacity.  There  was  redness  and 
swelling  upon  the  flexor  surface  of  the  forearm  involving 
particularly  the  lower  third.  The  swelling  upon  the  back 
of  the  hand  was  ascribed  to  edema.  The  fingers  were  flexed 
at  an  angle  of  45  degrees,  while  the  metacarpal  bone  of  the 
thumb  set  back  from  the  hand  and  the  distal  phalanx  of  the 
thumb  was  sharply  flexed.  The  diagnosis  of  pus  in  the  middle 
palmar  space,  thenar  space,  the  forearm  under  the  profundus 
tendons,  and  the  probable  involvement  of  the  common 
synovial  sheath  in  the  palm  was  made.  Owing  to  the  inade- 
quate incision  already  made  in  the  palm,  this  was  chosen  as 
the  proper  site  for  exploration.  The  incision  having  been 
carried  through  the  palmar  fascia,  pus  was  found  in  the  posi- 
tion designated,  with  an  involvement  of  the  ulnar  bursa  from 
the  base  of  the  little  finger  to  the  forearm.  The  bursa  was 
opened  throughout  its  length,  cutting  through  the  anterior 
annular  ligament.  The  major  portion  of  the  pus,  however, 
lay  outside  the  sheath.  An  artery  forceps  was  inserted  under 
the  tendons  of  the  palm  below  the  sheath  and  a  large  ostium 
made.  An  artery  forceps  was  then  thrust  through  the  parti- 
tion between  the  thenar  and  middle  palmar  spaces  at  the 
base  of  the  hand  lying  on  the  volar  side  of  the  transversus 
poUicis,   coming  out  between  the  metacarpal   bones  of  the 


282       rilEATMRNT  OF  FASCIAL  SPACE  ABSCFISSFS 


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Fig.  107. — Case  XV'I  before  and  after  incision.  Note  the  artery  forceps 
through  from  the  dorsum  into  the  thenar  space.  In  this  case  the  anterior  annu- 
lar ligament  was  cut. 


TREATMENT  OF  PALMAR.  AND  THENAR  SPACES    2S3 

thuinl)  and  index  linger.  A  drainaj^c  strip  was  then  drawn 
through  this  space  of  the  pahn  and  left  in  eighteen  hours. 
The  incision,  which  was  carried  through  the  anterior  annular 
ligament  to  the  forearm,  exposed  a  large  abscess  lying  under- 
neath the  tendons  of  the  flexor  profundus  digitorum  upon  the 


Fig.    108. — Case  XVI,   showing  result   three   months  after  treatment.     Note 

perfect  function. 

pronator  quadratus  and  interosseous  membrane.  The  incision 
was  extended  for  three  inches  up  on  the  forearm  to  open  this 
space  completely.     Hot  boric  acid  dressings  were  applied. 

Course. — Immediate  subsidence  of  temperature  and  septic 
symptoms.      In   ten  days  complete  cessation  of  discharge, 


284        TREATMENT  OF  FASCIAL  SPACE  ABSCESSES 

and  in  two  weeks  all  wounds  were  healed.  In  llirei'  weeks 
the  patient  was  usin^  his  hand  with  75  per  cent,  of  function, 
and  in  five  weeks  complete  function  was  present,  as  demon- 
strated by  accomi)anying  photographs  (Figs.   107  and   108). 

This  case  was  one  of  the  worst  that  ever  came  to  my 
notice.  We  were  fortunate,  however,  in  that  no  necrosis 
of  the  tendons  had  taken  place.  The  rapid  and  complete 
recovery  can  be  ascribed  only  to  the  thorough  opening  of 
every  pocket  of  pus  by  incisions  that  did  not  endanger 
previously  uninvolved  areas.  We  should  also  note  that 
the  annular  ligament  was  cut. 

The  Treatment  of  Combined  Involvement  of  the  Middle  Palmar 
AND  Subaponeurotic  Spaces. 

At  times  we  will  have  crushing  injuries  of  the  hand 
in  w^hich  the  metacarpal  bones  are  fractured.  Here  the 
subaponeurotic  space  on  the  dorsutn  is  involved  in  con- 
junction with  the  middle  palmar  space  (Case  VIII).  In 
such  cases  the  through-and-through  drainage  so  much 
in  vogue  among  the  older  surgeons  is  indicated.  Let  us 
study  where  such  drainage  can  be  safely  instituted  if  it  is 
indicated.  Such  a  point  should  be  chosen  as  will  give  the 
most  satisfactory  outlet  to  all  the  diverticula,  and  at  the 
same  time  injure  the  fewest  structures.  Here  the  value 
of  our  x-ray  plates,  with  the  cross-sections  and  injections, 
is  invaluable.  We  see  that  the  mass  always  lies  over  the 
interosseous  space  between  the  ring  and  middle  fingers, 
and  that  an  opening  here  will  drain  all  the  pockets  (Fig. 
109).  Our  incision,  however,  must  lie  proximal  to  the 
superficial  transverse  ligament.  (See  cross-section.  Fig. 
74;  x-ray,  Fig.  iii).  Secondly,  it  must  lie  to  the  radial 
side  of  the  ulnar  bursa  (x-ray  plate.  Fig.  no),  and  must  be 
to  the  ulnar  side  of  the  middle  metacarpal,  or  it  will  enter 
the  thenar  space.  This  again  throws  the  incision  into  the 
metacarpal  space,  between  the  middle  and  ring  fingers. 
Thus  we   see   that   not  only   are   the  fewest  structures 


Fig.  109. — X-ray  plate  made  from  a  hand  in  which  the  middle  palmar  space 
was  injected  with  a  mixture  of  red  lead  and  plaster  of  Paris.  Photograph  repre- 
sents location  of  pus  in  typical  middle  palmar  space  infection. 


Fig.   110. — X-ray  plate,  representing  the  location  of  pus  in  the  thenar  space, 
with  its  relation  to  the  ulnar  bursii. 


286       TREATMENT  OF  FASCIAL  SPACE  ABSCESSES 

injured  at  this  site,  but  also  the  most  perfect  drainage  is 
instituted. 


Fig.  hi. — X-ray  picture  showing  the  boundaries  of  the  thenar  and  middle 
palmar  spaces  {MPS)  marked  and  the  proper  site  for  opening  the  latter  indi- 
cated.    The  ulnar  bursa  and  bloodvessels  are  injected. 

Now  let  us  consider  where  an  incision  should  lie  in 
this  space.  An  examination  of  the  .x'-ray  picture  (Fig.  1 1 1 ) 
shows  the  deep  palmar  arch  running  across  this  area,  at 


TREATMENT  OF  ABSCESSES  IN  THENAR  SPACE    287 

the  upper  end;  the  fine  lines  drawn  transversely  represent 
the  dense  transverse  ligament  while  the  curved  lines 
represent  the  palmar  creases.  It  is  thus  seen  that  at  the 
point  where  the  middle  palmar  crease  crosses  the  meta- 
carpal space  should  be  the  indicated  site  for  drainage. 
Making  a  cut  here  through  the  palmar  aponeurosis,  and 
then  forcing  a  pointed  artery  forceps  through  to  the 
dorsum,  being  careful  to  rupture  the  dorsal  aponeurosis 
freely,  we  draw  through  a  large  twisted  rubber-dam  strip. 
At  this  site  there  is  little  danger  of  a  pressure  necrosis 
of  the  ulnar  bursa  or  the  palmar  arches. 

TECHNIQUE  OF  TREATMENT  OF  ABSCESSES  IN  THE  THENAR 

SPACE. 

.  Should  the  thenar  area  be  involved,  the  indications  for 
radical  operation  are  absolute,  even  upon  less  evidence 
than  in  the  case  of  palmar  infection,  since  here  the  dangers 
of  delay  are  greater,  and  the  consequences  of  opening  the 
space,  even  though  uninfected,  are  not  serious  (see  Case 
VI,  in  which  space  was  opened  when  uninfected,  under 
mistaken  diagnosis).  Here  the  pus  lies  either  anterior 
to  the  adductor  transversus,  or  upon  both  its  dorsal  and 
palmar  surface.  Theoretically,  the  most  available  place 
to  open  would  lie  to  the  radial  side  of  the  index  metacarpal, 
where  a  free  incision  would  drain  both  in  front  of  and 
behind  the  adductor.  We  therefore  make  an  incision 
through  the  dorsum,  on  the  radial  side  of  the  index  meta- 
carpal and  opposite  its  middle,  and  on  a  level  with  its 
flexor  surface.  An  artery  forceps  is  then  thrust  into  the 
thenar  space  across  the  flexor  surface  of  the  index  meta- 
carpal. This  gives  perfect  drainage  and  leaves  no  scar 
upon  the  flexor  surface  of  the  hand.  Care  should  be  taken 
not  to  pass  the  artery  forceps  beyond  the  middle  meta- 
carpal bone,  for  fear  of  spreading  the  infection  to  the 
middle  palmar  space  (Fig.  112). 

Illustrating  these  facts,  the  following  case  may  be  cited: 


288        TREATMEM'  OE  EASC/AL  SPACE  ABSCESSES 

Cask  X\'II.  K.,  injured  S(']jtcinhcr  3,  1904.  'Ilic  sharp 
point  of  a  meat  lon^s  ran  intcj  the  thenar  area  ujjon  the  level 
of  the  extended  thumb  aJKUit  2  cm.  from  the  thenar  adductor 
crease.  Pain  and  >\vellin^  ensuefi  the  foll(n\in^  day.  C)n 
September  5,  he  ccmsulted  a  physician,  who  fcnmd  much 
redness  and  swelling  upon  the  dorsal  thenar  area  and  made 


Fig.  112. — Showing  incisions  made  iiijon  the  dorsum  of  the  hand.  That 
upon  the  thenar  space  is  made  to  drain  the  thenar  space  in  the  pahii.  Those 
upon  the  distal  part  are  made  to  drain  extensions  from  the  palmar  space  to  the 
dorsum  and  the  so-called  collar-button  abscesses  when  they  e.xtfnd  to  the  dorsum. 


an  incision  there,  hut  evidently  failed  to  evacuate  pus.  Hot 
dressings  were  applied,  and  two  days  later  patient  presented 
himself  at  the  Northwestern  University  Surgical  Dispensary 
for  treatment.  There  was  considerable  swelling  of  the  whole 
hand,  but  distinctly  greater  ujxm  the  radial  side.  Dorsal  thenar 
area  had  slightly  greater  swelling  present  than  jjalmar  thenar 
area.     Upon  inspection  it  was  not  difificult  to  see  that  the 


ABSCESSES  IN  SUBAPONEUROTIC  SPACE  289 

thenar  area,  as  a  whole,  was  much  more  swollen  than  the 
remainder  of  the  hand.  Adduction  thenar  crease  was  the 
dividing  line.  Thumb  metacarpal  fully  abducted,  proximal 
phalanx  semiflexed,  distal  phalanx  fully  flexed,  giving  an 
almost  spastic  look  to  the  hand.  The  finger  phalanges  were 
all  semiflexed.  The  flexion  of  the  index  finger,  however, 
was  more  rigid  than  that  of  the  other  three,  and  movement 
of  it  and  the  thumb  caused  more  pain  than  the  three  ulnar 
fingers.  Both  epitrochlear  and  axillary  glands  slightly 
enlarged  and  tender.  Old  incision  upon  dorsal  thenar  region, 
from  which  small  amount  of  pus  was  exuding.  Temperature, 
101°;  pulse,  90.  Tenderness  marked  over  palmar  thenar 
area. 

Diagnosis. — Abscess,  thenar  space.  Operation:  Under 
nitrous  oxide  anesthesia  incision  made  into  thenar  area  at 
about  the  same  site  as  the  wound;  much  pus  evacuated. 
Gutta-percha  drainage  established;  hot,  moist  boric  dressings 
applied.  September  7,  swelling  almost  subsided,  still  dis- 
charge of  much  pus.  Temiperature,  99°;  pulse,  84.  Treat- 
ment continued.  Cultures  taken;  typical  Staphylococcus 
aureus  colonies,  methylene  blue  and  Gram's  stains;  Staphylo- 
coccus aureus.  September  9,  hand  much  better,  drainage 
removed,  hot  dressings  reapplied.  September  11,  hand  in 
good  condition;  dry  dressings  applied.  Following  this, 
patient  made  a  rapid  recovery.  Seen  July,  1905.  No  con- 
traction; function  perfect. 


TECHNIQUE  OF  TREATMENT  OF  ABSCESSES  IN  SUB- 
APONEUROTIC SPACE. 

If  the  subaponeurotic  space  be  involved,  we  should 
remember  that  the  tendons  proper  in  the  lower  part  of 
the  dorsum  overlie  the  metacarpal  bones,  except  the 
tendon  going  to  the  little  finger;  consequently  our  incision 
should  lie  over  the  interosseous  space.  Moreover,  any 
deep  transverse  incision,  if  too  long,  would  cut  the  tendon, 
while  a  simple  longitudinal  incision  would  tend  to  close. 
Therefore,  in  making  our  incision  and  drainage,  these  two 
factors  should  be  taken  into  consideration  and  an  adequate 
opening  provided,  which  does  not  injure  the  tendon. 
19 


290        TREATMENT  OF  FASCIAL  SPACE  ABSCESSES 

Those  cases  complicated  with  middle  palmar-space  infec- 
tion have  already  been  discUvSsed  (p.  284). 

//  the  injection  has  spread  up  under  the  annular  ligament 
into  the  forearm,  the  pus  will  lie  beneath  the  tendons  of  the 
flexor  profundus  and  upon  the  pronator  quadratus.  The 
best  method  of  emptying  this  abscess  would  be  to  go 
laterally,  just  anterior  to  the  radius  and  ulna  about  three 
inches  from  the  wrist.  A  complete  description  of  the 
method  of  treating  these  cases  will  be  found  in  Chapter 
XXVIII. 

AFTER-TREATMENT  IN  FASCIAL-SPACE  ABSCESSES. 

After  any  of  these  procedures  the  usual  hot,  moist 
dressings  are  applied  until  we  feel  that  extension  of  the 
process  has  ceased,  when  they  should  be  abandoned, 
since  the  continuation  of  the  enlargement  of  the  vessels 
incident  to  their  use  results  in  increasing  edema  and 
ultimately  lessening  resistance,  owing  to  improper  circu- 
lation; hence  they  become  a  menace  to  the  part  rather 
than  a  help.  At  this  stage  elevation  of  the  part  will  be 
found  to  be  of  material  aid.  Immobilization  should  be 
kept  up  as  long  as  there  is  any  danger  of  muscular  action 
disseminating  the  infection.  As  soon  as  this  stage  has 
passed,  however,  active  and  passive  movements  should 
be  encouraged  at  once,  with  the  idea  of  assisting  in  the 
absorption  of  the  excessive  edema,  as  well  as  assisting  in 
the  prevention  of  tendon  and  joint  adhesions.  I  fre- 
quently begin  these  on  the  second  day. 


CHAPTER  XVIII. 

RESUME  OF  ACUTE  SUPPURATIVE  TENO- 
SYNOVITIS AND  FASCIAL-SPACE 
ABSCESSES— PROGNOSIS. 

RESUME. 

Success  in  the  treatment  of  tendon-sheath  infections 
of  the  hand  depends  upon  early  accurate  diagnosis^upon 
incisions  so  made  as  to  drain  the  proper  sites  without 
involving  uninfected  areas,  and  upon  careful  after- 
treatment. 

Two  types  must  be  recognized,  the  fulminating  and 
the  subacute.  The  treatment  will  vary  with  the  type. 
The  most  marked  symptoms  and  signs  are:  Localized 
excruciating  tenderness  over  the  course  of  the  sheath, 
pain  on  extension,  especially  at  the  proximal  end  of  the 
sheath,  and  the  characteristic  position  of  the  finger. 

Infection  from  the  tendon  sheath  of  the  index  finger 
will  most  often  extend  to  the  lumbrical  spaces  and  the 
thenar  space  and  less  often  to  the  proximal  interphalangeal 
joint,  and  the  surface  at  the  proximal  end  of  the  sheath. 

From  the  middle  finger  it  most  often  extends  to  the 
lumbrical  spaces  and  middle  palmar  spaces  or  at  times 
the  thenar  space  and  less  often  to  the  proximal  interpha- 
langeal joint,  and  the  surface  at  the  proximal  end. 

From  the  ring  finger  the  extensions  are  the  same  except 
that  they  always  involve  the  middle  palmar  space  if 
extension  takes  place  into  the  palm. 

From  the  little  finger,  the  most  common  sites  of 
extension  are  the  lumbrical  space,  the  middle  palmar 
space,  and  the  ulnar  bursa,  less  commonly  to  the  proximal 
interphalangeal  joint  and  the  surface  at  the  proximal  end 


292      TENOSYNOVITIS  AND  FASCIAL  SPACE  ABSCESSES 

of  the  sheath.  From  the  ulnar  bursa  it  may  extend  to 
the  middle  palmar  space,  radial  bursa,  interosseous  space 
below  the  flexor  profundus,  and  the  wrist-joint.  From 
the  sheath  of  the  flexor  longus  pollicis  to  the  thenar  space, 
ulnar  bursa,  wrist-joint,  and  interosseous  space  above 
described. 

Incisions  should  be  too  radical  rather  than  too  conserva- 
tive. Incisions  ^re  best  made  in  the  fingers,  upon  one 
side  of  the  tendon  sheath  over  the  length  of  the  shaft  of 
the  middle  and  proximal  phalanx,  avoiding  the  joints, 
and  into  the  proximal  end  of  the  sheaths  or  the  lumbrical 
spaces  to  provide  drainage  there.  Exceptionally  it  may 
not  be  necessary  to  make  this  incision  throughout  its 
entire  extent.  Complete  splitting  along  one  side  should 
be  done  in  case  of  doubt,  since  the  adequacy  of  drainage 
should  be  the  first  requisite. 

The  ulnar  bursa  is  best  treated  by  splitting  it  through- 
out its  length,  cutting  upon  the  ulnar  side.  The  anterior 
annular  ligament  may  be  cut  ii  necessary.  This  is 
commonly  supplemented  by  incisions  upon  the  radial  and 
ulnar  sides  of  the  forearm  above  the  wrist-joint,  and  on 
a  level  with  the  flexor  surface  of  the  bones;  through-and- 
through  drainage  is  then  carried  out  under  the  flexor 
profundus  tendons.  An  ulnar  incision  may  be  sufficient. 
If  the  pus  has  invaded  the  forearm,  an  ulnar  incision  is 
made  at  the  middle  of  the  forearm  between  the  flexor 
carpi  ulnaris  and  the  flexor  sublimis,  or  between  the 
flexor  carpi  ulnaris  and  the  ulna. 

Incision  of  the  flexor  longus  pollicis  sheath  is  made 
from  a  finger-breath  below  the  anterior  annular  ligament 
to  the  end  of  the  sheath.  Opening  may  be  made  above 
the  anterior  annular  ligament,  the  upper  half  of  w^hich 
may  be  cut.  However,  drainage  may  be  better  instituted 
above  the  wrist  by  the  lateral  incision  mentioned  under 
ulnar  bursal  infections. 

In   the  after-treatment   the   Bier  constrictor  may   be 


PROGNOSIS  20:; 

used  for  a  few  hours,  hot,  inoisl.  dressinj^s  for  two  to  lour 
days,  followed  by  dry  dressing's,  the  hand  hein.u  held  in 
overextension  by  splint  and  daily  manipulation  of  joints 
and  muscles  after  immediate  danger  of  systemic  infection 
has  ended. 

There  may  be  accumulations  of  ])us  in  any  of  the 
six  fascial  spaces  I  have  described,  to  the  exclusion  of 
any  or  all  the  others,  namely,  the  middle  palmar,  thenar, 
lumbrical,  hypothenar,  dorsal  subaponeurotic,  dorsal 
subcutaneous.  These  may  be  involved  separately  or  in 
conjunction  with  the  tendon  sheaths.  The  middle  palmar 
space  with  its  diverticula  along  the  three  lumbrical 
muscles  is  best  drained  by  an  incision  along  a  lumbrical 
canal  carried  up  to  the  space.  The  thenar  space  is  best 
drained  by  an  incision  on  the  dorsum  to  the  radial  side 
of  the  index  metacarpal.  Hypothenar  abscesses  are 
localized  and  can  be  drained  by  simple  incision.  All 
forearm  extensions  may  be  drained  by  lateral  incisions 
above  the  wrist,  the  drainage  being  inserted  under  the 
tendons  of  the  flexor  profundus  digitorum. 

PROGNOSIS. 

The  life  of  the  individual  is  frequently  jeopardized 
in  either  of  these  types  of  infections.  Undoubtedly  if 
proper  treatment  is  instituted  the  danger  will  be  reduced 
to  a  minimum.  The  lymphatic  infections  which  will  be 
discussed  in  the  subsequent  chapters  are  the  most  fre- 
quent source  of  death.  The  fulminating  type  of  tendon- 
sheath  infections  may  cause  death,  but  the  more  chronic 
type,  as  ^Iso  the  fascial-space  abscesses,  should  have  few 
fatalities  except  in  neglected  cases.  Especial  caution 
should  be  exercised  in  giving  a  favorable  prognosis  in  the 
aged,  since  the  prognosis  grows  rapidly  worse  after  forty. 
The  presence  of  a  nephritis  is  also  of  serious  import. 

It  is  very  nearly  impossible  to  state  from  a  study  of 
the  literature  what  proportion  of  cases  may  hope  for  a 
satisfactory    local    outcome.     The    authors    base    their 


204      TENOSYXOVrnS  AND  FASCIAL  SPACE  ABSCESSES 

statistics  111)011  different  classifications.  "Cood  result" 
is  used  by  some  to  designate  a  recovery  without  loss 
of  any  part  of  the  hand,  with  function  at  the  wrist  and 
in  the  uninvolved  fingers,  while  others  insist  upon  a  com- 
plete restoration  of  the  function  in  the  finger  as  well. 
It  is  to  be  hoped  that  in  the  future  the  statistics  may  be 
more  accurate.  From  my  personal  experience,  however, 
I  feel  that  the  following  statements  may  be  made.  A 
complete  functionating  hand  can  always  be  promised  in 
acute  infections  of  the  hand,  not  involving  the  tendon 
sheaths,  unless  necrosis  of  tissue  has  taken  place  or  joint 
involvement  has  occurred.  'That  is  to  say,  abscesses  of 
the  middle  palmar  space,  thenar  space,  and  forearm,  as 
well  as  simpler  conditions,  can  be  treated  with  a  perfect 
functionating  result.  This  has  occurred  in  my  experience 
even  after  four  or  five  wrecks  of  inadequate  treatment. 
In  tendon-sheath  infection,  however,  the  results  are  not 
nearly  so  good.  By  proper  and  early  treatment  a  perfect 
result  can  generally  be  assured  as  to  function  of  the  wrist- 
joint,  hand  and  fingers  not  involved.  Where  the  tendon 
sheath  of  a  finger  is  involved,  unless  early  treatment 
is  instituted,  flexion  of  the  phalanges  of  that  finger  is 
likely  to  be  lost,  while  flexion  at  the  metacarpo-phalangeal 
articulation  may  generally  be  preserved.  In  early  cases 
or  under  exceptional  circumstances  complete  function 
may  be  secured.  In  the  thumb,  even  though  the  function 
of  the  flexor  longus  pollicis  is  lost,  the  hand  will  not  be 
seriously  impaired,  since  the  smaller  muscles  of  the  thumb 
wall  give  it  such  function  that  the  impairment  will  not  be 
as  serious  by  any  means  as  in  the  fingers.  Extension 
from  tendon  sheaths  to  the  forearm  should  be  looked  upon 
with  anxiety,  and  if  serious  complications  or  sequelae  are 
present,  the  patient  must  be  warned  that  the  course  may 
be  long  and  the  ultimate  restoration  of  function  depend 
much  upon  continue'd  and  faithful  application  of  after- 
treatment. 


SECTION     III. 
LYMPHATIC  INFECTIONS. 

CHAPTER  XIX. 

THE  RELATION  OF  LYMPHANGITIS  TO  OTHER 

TYPES  OF  INFECTION— DISCUSSION 

OF  THE  ANATOMY. 

THE  RELATION  OF  LYMPHANGITIS  TO  OTHER  TYPES  OF 
INFECTION. 

Lymphangitis  may  be  of  two  types,  superficial  and 
deep.  Of  these,  the  superficial  is  most  common,  owing 
to  the  fact  that  sHght  abrasions,  superficial  fissures,  and 
small  punctures,  disregarded  by  the  patient  because  they 
are  considered  of  no  importance,  are  generally  the  source. 
These  lie  in  the  superficial  tissues  and  lead  to  a  superficial 
or  subcutaneous  infection.  The  rarer  type,  deep  lym- 
phangitis, undoubtedly  may  occur.  When  it  does, 
however,  it  develops  as  a  complication  of  superficial 
lymphangitis  or  as  a  sequence  of  deep  injury,  and  when 
such  deep  injury  occurs  the  wound  is  generally  consider- 
able, so  that  the  lymphangitis  is  of  secondar^^  importance 
to  the  local  condition. 

For  the  sake  of  study,  lymphangitis  must  be  sharply 
differentiated  from  tenosynovitis  and  fascial-space  infec- 
tion. It  is  true  that  in  a  large  number  of  cases  a  teno- 
synovitis or  fascial-space  infection  may  develop  from  a 
lymphangitis,  but  it  is  also  true  that  in  a  majority  of 
cases  neither  complication  ensues  unless  ill-advised  surgery 
produces  them.  Under  pathogenesis  I  shall  discuss  these 
complications  in  full,  and  under  symptomatology-  shall 
try  to  suggest  the  various  points  which  may  ser\'e  to 
differentiate  them  when  they  are  separate  conditions  or 


290    LYMPHANGITIS  AXD  OTHER   TYPES  OF  INFECTION 

may  serve  to  diagnosticate  their  (le\elo])nient  when  they 
arise  in  the  course  of  a  pure  Kniphalic  infecti(;n.  Owing 
to  the  intimate  rehition  of  Kmphangitis  to  sei^ticemia,  it 
has  seemed  wise  to  associate  the  discussion  of  the  former 
with  that  of  the  latter,  and,  for  the  sake  of  the  clinical 
picture,  to  consider  in  relation  to  them  the  various  severe 
infections  jeopardizing  life,  such  as  gas  bacillus  infections 
and  anthrax.  A  complete  discussion  of  tenosynovitis 
and  fascial-space  abscesses  may  be  found  in  the  preceding 
chapters. 

ANATOMY. 

In  order  to  understand  the  pathogeny  of  lymphatic 
abscesses,  an  accurate  knowledge  of  the  position  and 
course  of  the  lymphatic  vessels  is  absolutely  essential. 
The  masterful  work  of  Mascagni  and  later  work  by 
Sappey  have  been  fully  reviewed  and  verified  b}'  Poirier, 
with  the  assistance  of  his  pupil  Cuneo,  making  use  of 
Gerota's  process  of  injection,  and  the  following  is  largely 
quoted  from  their  treatise  upon  that  subject.  We  so 
often  see  the  superficial  lymphatics  in  the  course  of 
surgical  practice  that  we  are  inclined  to  forget  that  there 
are  deeper  lymphatics  which  follow  the  deeper  vessels. 
Sappey  believed  that  these  two  systems  were  absolutely 
independent.  Poirier,  however,  maintains  that  com- 
munication is  fairly  common,  especially  in  the  articular 
regions.  It  is  important  to  remember  that  the  principal 
lymphatic  vessels  and  glands  lie  superficial  to  the  large 
veins  and  seldom  deep.  The  clinical  significance  of  this 
is  apparent  to  the  surgeon.  Another  general  point  of 
importance  is  that  the  texture  of  the  surrounding  con- 
nective tissue  influences  their  shape  and  number.  If  the 
connective  tissue  is  lax,  their  tendency  is  to  run  together 
and  become  sinuous  and  sacciform  (Fig.  113).  Conse- 
quently the  infection  is  likely  to  localize  in  the  looser 
connective-tissue  areas.     This  probability  is  accentuated 


ANATOMY 


297 


by  the  fact  that  i>hinds,  either  iiiicros(:{)])ic  or  macroscopic, 
show    a    predilection    for    these    areas.     'IMie    fact    that 


^mmvA 


'"■!»V  ■• 


Fig.  113. — Drawing  showing  lymphatics  grouped  about  a  hair^  follicle  on 
the  dorsum.  Character  of  lymphatic  tissue  commonly  seen  in  loose  connective- 
tissue  spaces.     (After  Sappey.) 

sacciform  dilatations  and   microscopic  glands  do  occur 
explains  the  production  of  abscesses  in  the  course  of  an 


208    LYMPIIAXGJTJS  A  XI)  OrilKR   TV  PES  OF   JXFRCTTON 

a])parcMill\  uninterrupted  hniphatic.  Moreover,  the 
varial)ilil>  both  in  the  number  and  the  position  of  these 
glands  renders  absolute  statements  as  to  their  position 
impossible.  Not  alone  are  microscopic  glands  present  in 
the  course  of  the  vessels;  Gulland  has  demonstrated  them 
in  the  axilla,  and  Stiles  has  seen  axillary  glands  appear 
during  lactation  and  disappear  on  its  cessation.  How- 
ever, this  may  be  stated:  In  a  given  animal  and  a  given 
region  the  quantity  of  glandular  tissue  is  always  practically 
identical.  Thus  if  the  glands  are  small  they  are  numerous, 
and  if  large  they  are  likely  to  be  scarce.  In  any  case, 
however,  they  are  generally  paravascular. 

The  Lymphatic  Vessels  of  the  Hand  and  Forearm. 

These  may  be  divided  into  two  groups:  the  superficial 
lymphatics,  which  arise  from  the  integument  and  whose 
collecting  trunks  run  in  the  subcutaneous  cellular  tissue; 
and  the  deep  lymphatics,  arising  in  the  deeper  tissues  and 
in  vessels  following  the  deep  bloodvessels. 

Superficial  L^'mphatics. 

These,  being  easily  demonstrated  experimentally  and 
seen  so  often  clinically,  are  well  known. 

"The  superficial  lymphatics  come  from  all  parts  of 
the  cutaneous  covering  of  the  limb,  but  it  is  in  the  fingers 
(Fig.  114)  and  the  palm  of  the  hand  that  the  net- work  of 
origin  is  the  richest.  It  is  therefore  at  these  points,  and 
more  particularly  on  the  palmar  surface  of  the  fingers, 
that  punctures  must  be  made  for  the  injection  of  the 
lymphatics  of  the  upper  limb. 

"The  collecting  trunks  of  the  superficial  net-work 
appear  at  the  roots  of  the  fingers  and  at  the  base  of 
the  palm  of  the  hand  (Fig.  115).  They  then  run  upward 
on  the  forearm  and  arm,  receiving  as  they  ascend  the 
lym])h  from  other  parts  of  the  cutaneous  covering.  They 
terminate  in  the  glands  of  the  axilla.     We  will  study  first 


SUPERFICIAL   LVMrilATICS  200 

their  diiiital  and  palmar  oriLiiii,  and  tlu-ii  I  heir  coursi- and 
termination. 

"Origins:  (.1)  \\\  the  lingers,  the  net-wori^  of  origin 
presents  its  maximum  of  development  on  the  palmar 
surface  (Fig.  ii6).  Here  the  meshes  are  so  closely  set 
that  it  is  only  by  a  careful  examination  with  a  lens  that 
they  can  be  distinguished.  The  dorsal  net-work  is  much 
less  rich  than  the  preceding  (Fig.  117).  From  these  two 
net-works  arise  a  considerable  number  of  collectors,  which 
converge  toward  the  sides  of  the  fingers  and  unite  to  form 
two  or  three  trunks  on  each  of  these  surfaces  (Fig.  114). 


Fig.  114. — Net-work  of  lymphatics  on  the  side  of  the  finger.  The  accom- 
panying drawing  represents  the  trunklets  which  carry  the  lymphatic  stream 
to  the  base  of  the  finger.     (Alter  Sappey.) 

These  trunks  at  first  follow  the  corresponding  collateral 
artery,  but,  having  arrived  at  the  base  of  the  finger,  they 
incline  backward  and  run  toward  the  interdigital  space. 
They  then  pass  to  the  posterior  surface  of  the  hand,  and 
are  directed  toward  the  wrist,  where  we  shall  trace  them 
again  shortly.  In  their  course  on  the  dorsal  surface  of  the 
hand  they  effect  numerous  anastomoses.  They  cross 
one  another  frequently,  and  it  is  no  unusual  thing  to  see 
a  collecting  trunk,  which  has  arisen,  for  example,  in  the 
fourth  interdigital  space,  uniting  with  trunks  which  run 
along  the  external  part  of  the  dorsal  surface  of  the  hand. 


;]00    LYMPHANGITIS  AND  OTHER   TYPES  OF  INFECTION 


^ 


Fig.  115.— Showing  lymphatics  of  a  hand  and  arm,  the  areas  of  origin  and 
distribution.     (After  Sappey.) 


suPERFin.ir  LVMriiATics  \m 

"(B)   In  the  palm  of  the  haiKl   the   lU't-uork  of  ori.uiii 
is  also  cxtrcmeh-  rich.      From  this  net-work  rim  luimcrous 


Fig.  116. — Showing  extensive  net-work  of  lymphatic  channels  on  the  palm 
and  fingers,  with  their  e.xtensions  to  the  dorsum  and  to  the  forearm  through 
the  collecting  trunklets.     (After  Sappey.) 


302    LYMPHANGITIS  AND  OTHER  TYPES  OF  INFECTION 

trunklets,  which  we  may  divide  into  external,  internal, 
inferior,  superior,  and  central  (Fi^.  Ii8). 


F"lG.  117. — Showing  lymphatics  upon  the  dorsum.     Note  how  few  there  are  in 
comparison  with  those  upon  the  pahiiar  surface.     (After  Sappey.) 


"The  external  trunklets,  four  to  six  in  number,  run 
obliquely  upward  and  outward,  and,  crossing  the  surface 
of  the  thenar  eminence  in  a  slanting  direction,  terminate 


SUPERl'ICIA  L   L  YM  I'll.  I  TIL  \S 


'M'y 


in  the  l>'iuphatics  coniiiiL;   from   the  inle.uiimenls  of   the.- 
thumb. 

"The  internal  trunklets,  more  numerous  than  the 
preceding  (eight  or  ten),  run  ahiiost  transversely  inward, 
and,  crossing  the  ulnar  border  of  the  hand,  reach  the  dorsal 
surface  and  emi^ty  themselves  into  the  collecting  trunks 
which  arise  from  the  integument  of  the  little  finger. 


Fig.  118. — Lymphatic  vessels  of  the  palm,  showing  their  extensions  from 
all  the  borders  to  the  dorsum  and  the  extension  from  the  central  portion  into 
the  deep  lymphatic  along  the  palmar  arch.     (After  Sappey.) 


"The  inferior  trunklets,  w^hich  vary  from  twelve  to 
fifteen  in  number,  are  directed  toward  the  interdigital 
spaces;  they  then  reach  the  dorsal  surface  of  the  hand  and 
terminate  in  the  digital  collecting  trunks. 

"The  superior  trunklets  reach  the  anterior  surface  of 
the  wrist,- and  unite  to  form  three  or  four  trunks,  which 
ascend  on  the  anterior  surface  of  the  forearm. 

"The  central  trunklets  run  toward  the  deep  portion. 
They  traverse  the  subcutaneous  fatty  layer  and  the 
superficial  palmar  fascia,  and  they  usually  unite  into  a 
single  trunk.  The  latter,  which  has  been  well  described 
by  Sappey,   takes   the  following  course:     It  is  directed 


304     LVMPII.WGiriS  AM)  OTIIKK   TYPES  OF  IM'KCTION 

immediately  outward,  running  underneath  the  fascia 
in  front  of  the  flexor  tendons.  It  thus  comes  to  the 
adductor  transversus  pollicis,  crosses  the  inferior  border 
of  this  muscle,  and  then  crosses  the  outer  border  of  the 
first  dorsal  interosseous,  on  the  posterior  surface  of  which 
it  ascends.  1 1  there  joins  collectors  coming  from  the  index 
finger,  and  in  company  with  the  latter  reaches  the  dorsal 
surface  of  the  wrist. 

"Course:  All  these  collecting  trunks,  which  arise 
from  the  integuments  of  the  fingers  and  hand,  run  in  the 
subcutaneous  cellular  tissue  toward  the  root  of  the  limb. 
They  are  usually  more  sujierficial  than  the  veins  whose 
trunks  they  cover.  They  diminish  in  number  as  they  are 
traced  upward.  In  the  forearm  there  are  about  thirty, 
but  in  the  middle  of  the  arm  not  more  than  fifteen  to 
eighteen.      (Sappey.) 

"In  the  wrist  they  are  divided  into  two  groups,  of 
which  one  runs  on  the  dorsal,  the  other  on  the  palmar 
surface  of  this  ])art  of  the  limb. 

"In  the  forearm  they  tend  to  divide  themselves  into 
three  groujis — an  external  groujj,  which  ascends  along 
the  radial  border  of  the  forearm;  an  internal  group, 
which  follows  the  ulnar  border;  a  middle  group,  which  is 
a  satellite  of  the  median  vein  and  runs  between  the  two 
preceding. 

"A  little  l)elow  the  bend  of  the  elljow  the  two  lateral 
grouj)s  come  more  and  more  to  the  anterior  surface  of 
the  limb  and  unite  with  the  median  grouj);  on  the  dorsal 
surface  we  find  nothing  but  some  rather  small  collecting 
trunks,  which  incline  obliquely,  some  outward,  others 
inward,  and  reach  the  anterior  surface  of  the  arm  (Fig. 
115).  At  the  level  of  the  olecranon  these  collecting 
trunks  present  remarkable  sinuosities. 

"In  the  arm  the  difi"erent  collecting  trunks,  hence- 
forth united  into  a  single  bundle,  show  a  tendency  'to 
arrange  themselves  on  the  external  surface  of  the  arm, 
parallel  to  each  other. 


DEEP  LYMPHATICS  :i()5 

"Termination:  The  majority  of  these  collectors  run 
as  far  as  the  neighborhood  of  the  base  of  the  axilhi.  Here, 
they  perforate  the  deep  fascia  and  terminate  in  the 
humeral  chain  of  axillary  glands.  The  collectors  from 
the  outermost  and  innermost  parts  have  quite  a  different 
termination;  thus,  two  or  three  of  the  most  internal  end 
in  the  supra-epitrochlear  gland.  We  have  already  seen 
that  the  efferents  of  this  gland  perforated  the  deep  fascia 
in  the  middle  part  of  the  arm  and  end  in  the  deep  vessels. 
When  this  gland  is  absent,  we  may  nevertheless  see  the 
internal  collectors  perforating  the  fascia  at  the  same  point 
to  reach  the  deep  absorbents.  The  most  external  trunk 
is  also  remarkable  for  the  special  course  it  pursues.  It 
separates  itself  from  the  other  collectors  in  the  region  of 
the  humeral  insertion  of  the  deltoid,  then  ascends  in  the 
deltopectoral  groove,  where  it  may  traverse  one  or  several 
glands  which  we  have  indicated  above.  This  trunk 
usually  passes  into  a  subclavian  gland,  placed  at  the  spot 
where  the  cephalic  joins  the  axillary  vein.  It  may  also 
be  seen  to  pass  above  the  clavicle,  and  to  empty  itself  into 
the  supraclavicular  gland.  This  arrangement,  though 
somewhat  infrequent  (Grossman  says  38  out  of  100 
cases),  has  been  figured  by  Mascagni.  This  delto- 
pectoral trunk  is  sometimes  double  and  even  triple." 

Deep  Lymphatics. 

"The  deep  lymphatics  follow^  the  brachial  artery  and 
its  chief  branches.  There  are  usually  two  lymphatic 
trunks  for  each  artery.  With  Sappey,  we  will  divide 
these  deep  lymphatics  into  radial,  cubital,  posterior 
interosseous,  anterior  interosseous,  and  brachial. 

"The  radial  trunks  arise  from  the  subfascial  ])ortions 
of  the  palm  of  the  hand.  'One  accompanies  the  deep 
palmar  arch,  turns  around  the  head  of  the  first  meta- 
carpal bone,  and  runs  on  the  outer  side  of  the  carpus, 
and   reaches   the   forearm,    where   it  is  situated   on   the 


306    LYMPHANGITIS  AND  OTHER  TYPES  OF  INFECTION 

external  side  of  the  radial  artery;  the  other,  whose  origin 
is  not  so  deep,  follows,  according  to  the  sketch  left  us  by 
Mascagni,  the  course  of  the  radio-palmar  artery,  and  also 
joins  the  forearm,  where  it  is  placed  on  the  inner  side  of  the 
radial.  Both  then  ascend  as  far  as  the  bend  of  the  elbow, 
where  they  anastomose.  In  their  antibrachial  course 
they  traverse  one  or  two  small  glands,  the  existence  of 
which  is  not  constant.'     (Sappey.) 


Fig.  119. — Showing  lymphatics  about  a  hair  follicle.     (After  Sappey.) 

"The  ulnar  trunks  are  also  two  in  number.  They 
have  a  separate  origin.  One,  in.  fact,  appears  by  the 
side  of  the  superficial  palmar,  while  the  other  is  a  satellite 
of  the  deep  palmar  arch.  They  unite  at  the  wrist,  just 
above  which  they  receive  a  large  affluent  which  is  a  satel- 
lite of  the  dorsal  branch  of  the  ulnar.  They  then  run 
parallel  to  the  ulnar  vessels  as  far  as  the  bend  of  the  elbow. 
During  their  course  they  sometimes  present  one  or  more 
small  glands. 


DEEP  LYMPHATICS  :i()7 

"The  posterior  interosseous  trunks,  which  arise  from 
the  deep  muscles  of  the  forearm,  perforate  the  inter- 
osseous membrane  and  then  unite  at  the  bend  of  the 
elbow  with  the  preceding  vessels. 

"The  anterior  interosseous  trunks  follow  the  vessels 
of  this  name,  and,  after  presenting  in  their  course  one 
or  two  small  glands,  also  end  in  the  lymphatic  meeting- 
place  at  the  bend  of  the  elbow. 

"The  humeral  trunks  comprise  all  the  above-men- 
tioned antibrachial  collecting  trunks.  They  vary  from 
two  to  three  in  number.  They  run  b}'  the  side  of  the 
humeral  vessels,  and  terminate  in  the  humeral  group 
of  the  axillary  glands.  As  we  have  already  seen,  they 
present  in  their  course  some  small  glands  which  appear 
to  be  nearly  always  present.  In  the  middle  part  of  the 
arm  they  collect  the  efferent  vessels  from  the  supra- 
epitrochlear  gland.  They  also  receive  some  small  trunks 
from  the  muscles  of  the  arm." 


CHAPTER   XX. 

LYMPHANGITIS— ETIOLOGY,  PATHOGENESIS, 
AND  PATHOLOGY. 

PREDISPOSING  AND  ACTIVE  FACTORS  IX  THE  PRODUCTION 
OF  LYMPHANGITIS. 

While  a  lymphangitis  may  develop  at  any  time  of 
the  year,  it  is  most  frequently  observed  in  the  fall  and 
winter,  an  observation  that  is  concurred  in  by  all  authors. 
This  may  find  its  cause  in  the  unnatural  conditions  under 
which  workingmen  live  during  the  colder  months,  at 
which  time  they  are  closely  housed,  with  the  result  that 
they  breathe  impure  air,  and  because  of  this  and  the  lack 
of  outdoor  exercise  their  power  of  resistance  is  reduced. 
It  is  possible  that  the  colder  air  which  contracts  the 
superficial  vessels  may  have  some  bearing  on  the  develop- 
inent  of  the  infection  by  lessening  the  natural  protection 
against  superficial  injuries. 

The  source  is  most  often  some  slight  puncture,  carrying 
bacteria  beneath  the  surface,  or  the  small  crack  so  often 
found  in  workingmen's  hands,  especially  in  winter,  about 
the  calloused  areas,  the  so-called  durillon  force  of  the 
French  authors.  These  are  particularly  noted  at  the 
distal  part  of  the  palm,  where  dirt  incident  to  the  occupa- 
tion is  rubbed  into  the  fissures.  The  slight  punctures 
often  come  from  needles  or  pins,  and  are  thus  frequently 
found  on  the  distal  phalanx,  generally  being  so  slight  as 
to  have  been  forgotten  when  the  patient  applies  for 
treatment.  Again,  we  note  its  frequency  after  trauma  of 
the  nail.  The  patient  gives  a  history  of  running  a  splinter 
under  the  nail,  or  of  some  injury  which  has  caused  a 
separation  of  the  nail  from  its  bed,  with  a  small  sub- 
onychial  hemorrhage,  which  has  become  infected. 


FACTORS  /.V   TIIK  PKODLCTIOX  OI-    I.Y M rilAXCITIS     aO!) 

\\'h\-  it  is  thai  similar  injiirics  nui\-  be  followed  in  one 
case  1)\  scNiTi'  1\  inphanj^ilis  and  in  another  by  no  resnlts 
is  still  an  unanswered  cinestion.  We  are  accustomed  to 
sa>  that  the  resistance  of  the  patients  varies,  and  this  is 
undoubtedly  true.  On  the  other  hand  every  surgeon  has 
seen  nianx-  cases  of  severe  l\-mphangitis  in  patients  of 


Fig.  120. — Showing  lymphatics  in  the  pahii  of  the  hand.     (After  Sappey.) 

apparently  normal  resistance.  We  cannot  attribute  the 
cause  entirely  to  lessened  resistance.  It  is  possible  that 
some  bacteria  contain  inherent  cytolytic  attributes  which 
lessen  the  possibility  of  the  walling-ofT  process  and  fa\'or 
extension.  Many  investigators  have  studied  the  question 
and  added  individual  facts  to  our  knowledge,  which  is 
inadequate,   however,   for  a  complete   understanding  of 


310  ITMPnAXCJTlS 

the  subject.  Canon  showed  the  ligation  of  the  small 
intestine  favored  bacterial  growth  in  the  blood  stream, 
thus  showing  the  importance  of  proper  intestinal  action. 
He  also  thought  that  he  had  demonstrated  that  an  exces- 
sive acidity  of  the  blood  is  more  favorable  to  bacterial 
growth  than  any  alkalinity.  This,  however,  has  not 
been  verified. 

thp:  influence  of  the  type  of  germ. 

It  is  probable  that  almost  any  of  the  various  pathogenic 
bacteria  may  give  rise  to  lymphatic  infection.      In  a  great 
majority-  of  cases,  however,  the  streptococcus  will  be  found 
to  be  the  etiological  factor.     No  group  of  bacteria  can 
claim  more  varied  and  more  numerous  types  of  proved 
and  possible  pathogenic  activity  than  the  streptococci. 
The  classification  is  still  the  subject  of  a  great  deal  of 
controversy.     Attempts  have  been  made  to  classify  them 
according   to   the   size  or  appearance  of   the   individual 
cocci,  their  arrangement  in  pairs  rather  than  in  chains, 
the  length  of  the  chains  themselves,  according  to  their 
growth  in  culture  media,  according  to  their  sugar  fermen- 
tation, according  to  their  origin  and  according  to  their 
virulence.     It  is  possible,  however,  to  produce  variations 
in  a  pure  culture,  by  submitting  it  to  natural  or  artificial 
differences  in  environment,  which  would  suggest  any  of 
these  classifications.     The  action  of   the   streptococcus, 
nevertheless,  on  red  blood  corpuscles  is  most  significant 
and   important.     It    is   possible   to   differentiate   strains 
which  will  hemolyze  blood,  others  which  produce  green 
colonies  and  still  others  which  fail  to  produce  any  change 
on  blood.     This  has  given  rise  to  the  widely  used  classi- 
fication   of    Streptococcus    hemolyticus.    Streptococcus 
viridans  and  Streptococcus  non-hemolyticus.     The  major- 
ity of  authors  who  have  used  the  blood  method  have 
proceeded  further  to  classify  by  employment  of  carbo- 
hydrate tests.     Of  these,  Holman's  is  probably  the  most 


THE  INFLUENCE  OF  THE  TYPE  OF  GERM  311 

satisfactory  and  the  most  generally  used  classification  of 
the  streptococcus  group.  His  method  consists  in  a  pri- 
mary differentiation  of  hemolytic  and  non-hemolytic 
strains  by  streaking  out  on  blood  agar  followed  by  a 
further  segaration  of  each  by  the  action  on  three  sugars, 
lactose,  mannite  and  salicin.  The  result  of  this  is  sixteen 
types  of  streptococci,  eight  hemolytic  and  eight  non- 
hemolytic. Under  the  non-hemolytic  are  included  viri- 
dans  cultures  as  well  as  those  which  have  no  effect  upon 
blood  mediums.  Of  the  hemolytic  forms  Streptococcus 
pyogenes  and  Streptococcus  anginosus  are  the  most  impor- 
tant pathogenically.  The  individual  groups  of  streptococci 
are  not  specific  in  their  disease  production.  The  members 
of  the  hemolytic  group  are  commonly  rriore  virulent  and 
pathogenic,  producing  more  rapid  progressive  disease 
while  the  Streptococcus  viridans  or  mitis  is  found  particu- 
larly in  association  with  the  milder,  more  chronic  group 
of  infections  with  certain  definite  locations.  The  immu- 
nity tests,  so  far  as  carried  out,  seem  to  agree  with  bio- 
chemical reactions  and  indicate  that  the  hemolytic  group 
of  streptococci  are  closely  allied  and  are  separate  from  the 
viridans  strains. 

The  next  microorganisms  of  importance  are  those  of 
the  Staphylococcus  group.  The  most  noteworthy  mem- 
bers of  this  group,  in  this  connection,  are  the  Staphylo- 
coccus pyogenes  aureus,  the  Staphylococcus  pyogenes 
albus  and  the  Staphylococcus  pyogenes  citreus.  The 
Staphylococcus  pyogenes  aureus  is  characterized  by  a 
golden  yellow  pigment.  Separate  strains  show  Avide 
variations  in  relative  virulence;  the  most  highly  virulent 
usually  being  those  recently  isolated  from  human  sup- 
purative lesions.  Hemolysins  are  produced  by  Staphy- 
lococcus aureus  and  to  a  less  degree  by  Staphylococcus 
albus.  The  quantity  produced  varies  enormously  with 
different  strains  and  seems  to  be  roughly  proportionate 
to    the    virulence    of    the    particular    microorganisms. 


312  LYMPIIAXGTTIS 

Absolutely  avirulcnt  races  do  not,  ajiparently,  i^roduce 
hemolysins.  Sta])hylococcus  ])yo,uenes  £ilbus  differs  from 
Staphylococcus  pyogenes  aureus  simply  in  the  absence 
of  the  golden  yellow  pigment.  Morphologically,  cul- 
turally and  pathogenically  it  is  in  every  Avay  identical 
but  its  toxin  and  enzyme-producing  powers  in  general 
are  less  developed.  Staphylococcus  pyogenes  citreus 
forms  a  bright  yellow  or  lemon  colored  pigment.  It 
may  be  pyogenic  but  it  is  less  often  found  in  connection 
with  pathological  lesions  than  either  of  the  above.  Many 
of  the  other  types  of  bacteria  may  be  found  in  the  systemic 
infections,  even  the  Bacillus  pyocyaneus  has  been  found 
in  a  number  of  cases,  as  instanced  by  Roberts,  Finkelstein, 
and  Brill  and  Libman. 

Among  the  most  marked  characteristics  of  severe  infec- 
tions we  have  the  cytolytic  and  hemolytic  functions.  The 
semijaundiced  appearance  of  the  severe  cases  due  to  the 
hemolysis  is  a  well-known  picture,  and  while  most  often 
seen  with  streptococcus  infections,  it  may  also  appear  in 
the  staphylococcus  forms  to  a  marked  degree,  especially 
in  the  aureus  infections  and  to  a  lesser  degree  in  albus. 
This  staphylohemolysin  must,  however,  be  present  in 
considerable  amounts  before  its  effects  become  apparent 
in  man,  since  his  serum  contains  normally  small  amounts 
of  anti-staphylolysin,  as  was  shown  by  Neisser,  and, 
moreover,  if  the  inoculation  or  infection  begins  slowly,  the 
system  will  develop  larger  amounts. 

A  further  careful  study  of  the  effects  of  combined 
bacterial  infections  is  to  be  desired. 

The  effect  of  symbiosis  is  not  fully  known,  although  it 
has  been  hinted  at  by  various  investigators.  The  effect 
of  combined  streptococcus  and  staphylococcus  involve- 
ment is  of  special  interest,  since  we  so  often  see  this 
combination.  Fisher  and  Levy  suggest  that  the  strepto- 
coccus through  its  rapid  spread  prepares  the  soil  for  the 
staphylococcus.     When  this  occurs  the  prognosis  is  more 


THE  JNFLVKW'K  OF  ANATOMY  ON   THE  COURSE    ?A?> 

grave,  since  the  combination  seems  to  increase  the  viru- 
lence of  the  streptococci.  1  i)ersonally  have  oljserved 
that  such  cases  have  a  convalescence  prolonged  much 
beyond  the  ordinary  course  seen  in  patients  infected 
with  either  separately. 

THE  INFLUENCE  OF  THE  ANATOMY  ON  THE  COURSE. 

A  general  rule  which  the  anatomy  emphasizes  is  that 
from  an}^  given  point  the  superficial  lymphatics  pursue 
the  shortest  course  to  the  dorsum.  An  exception  is 
made  of  the  center  of  the  palm,  from  which,  as  has 
been  shown,  an  infection  would  tend  to  go  down  to  the 
superficial  palmar  arch.  These  are  rare,  however.  The 
general  rule  of  the  dorsal  extension  explains  the  frequency 
of  great  edema  on  the  back  of  the  hand  in  all  cases.  As 
specific  examples  of  the  importance  of  this  observation, 
those  infections  arising  at  the  distal  part  of  the  palm 
should  be  noted.  Here  the  lymphatics  first  go  distally, 
then  pass  around  the  web  and  onto  the  dorsum,  at  which 
site  the  swelling  and  redness  are  seen,  giving  rise  to  the 
assumption  on  the  part  of  the  thoughtless  that  the  infec- 
tion is  primarily  there.  This  is  then  followed  by  unneces- 
sary and  harmful  incisions.  A  little  care  would  have 
shown  that  the  starting-point  was  a  slight  fissure  in  the 
callus  on  the  flexor  surface,  and  that  the  dorsal  redness 
was  lymphatic  in  nature,  accompanied  by  an  inflammatory 
edema  which  would  be  harmed  rather  than  helped  by  an 
incision.  The  same  is  true  of  infections  upon  the  ulnar 
and  radial  sides  of  the  palm.  Where  there  is  localized 
redness  oh  the  dorsum  of  the  hand  we  less  often  see  the 
dorsal  lines  of  redness  running  up  the  arm.  These  are 
generally  the  accompaniment  of  an  absence  of  local 
reaction. 

Along  the  course  of  the  lymphvessels,  particularly' 
on  the  dorsum  of  the  hand,  will  be  found  areas  of  redness 
and  edema  about  twice  the  width  of  the  redness  accom- 


314 


LYMPlIAXGJriS 


panying  the  vessels,  appearing  as  if  the  infection  were 
locaHzing  there  or  as  if  small  abscesses  were  forming. 
These  may  be  incised  under  that  assumption.  It  is 
doubtless  true  that  in  the  semiacute  cases,  or  those  going 
on  to  abscess  formation,  the  localizing  processes  may 
start  from  these  foci,  but  great  care  should  be  exercised 


i 


Fig.  121. — Showing  lymphatics  in  the  skin  and  around  the  nail  in  a  child,  aged 
four  years.     (After  Sappey.) 

before  making  this  deduction,  since  these  are  but  the 
evidences  of  the  lacunae  mentioned  in  the  anatomical 
discussion,  and  generally  subside  at  the  same  time  the 
inflammation  disappears  from  the  vessel  proper. 

Attention  should  also  be  drawn  to  the  normal  course 
of  the  vessels,  and  it  should  be  emphasized  that  lymphatic 
extensions   from   the   little  and   ring  fingers   take  place 


rilK  INFLUENCE  OF  AXArOMY  OX   THE  COURSE    .SIT) 

through  the  cpitrochlear  lihiiuls,  then  to  the  axillary, 
while  infections  beginnini^  in  the  thumb  and  forefinger  go 
to  the  axillary  glands  without  the  interposition  of  the 
epitrochlear;  hence  systemic  infection  is  more  easily 
engendered,  and,  moreover,  if  the  observer  were  searching 
for  glandular  enlargement  he  would  not  expect  to  find  it 
at  the  elbow  in  these  cases.  Infections  beginning  in  the 
middle  finger  are  of  special  interest  in  that  either  the 
axilla  or  the  epitrochlear  glands  may  be  first  involved, 
and  in  some  cases  neither  of  these  areas  may  receive  the 
l^-mphatic  vessels,  since  they  may  pass  up  over  the  clavicle 
and  into  the  subclavian  glands  and  thus  directly  into  the 
circulation.  The  clinical  importance  of  this  lies  in  the 
fact  that  these  infections  may  reach  the  circulation  very 
early  and  because  of  the  rapidity  of  involvement  lead  to 
severe  and  even  fatal  systemic  infection.  I  have  had  one 
case  that  lends  support  to  this  assumption.  Therefore 
one  would  look  with  great  anxiety  upon  severe  infections 
arising  from  the  middle  and  index  fingers. 

In  some  of  the  patients  the  lymphatic  infection  rapidly 
spreads  from  the  lymphatic  vessel  and  extend  over  the 
entire  dorsum  of  the  hand  and  forearm  with  the  appear- 
ance of  an  erysipelas  without  the  raised  border.  The 
swelling-  is  considerable,  the  skin  takes  on  a  board-like 
hardness,  and  vesicles  may  appear  on  the  surface.  This 
may  subside  without  further  trouble,  but  very  often  sub- 
cutaneous tissue  soon  becomes  involved  and  dififuse 
abscess  formation  takes  place. 

These  are  ordinarily  virulent  cases  and  should  be 
carefully^ watched  and  the  abscesses  opened. 

There  is  an  intimate  relation  between  the  lymphatics 
of  the  distal  extremity  and  the  tendon  sheaths.  Of 
this  I  have  no  anatomical  proof,  but  such  clinical  evidence 
that  there  can  be  no  doubt  of  the  association.  It  has  been 
my  experience  frequently  to  meet  with  cases  in  patients 
with  pin  pricks,  especially  of  the  distal  phalanx,  which 


316 


LVMPHANGtriS 


lead  to  a  typical  lymphangitis  w  ith  a  red  line  running  up 
the  arm,  and  after  a  couple  of  days  these  would  show  the 
typical  evidences  of  tendon-sheath  infection  of  the  hnger 
involved.  The  distal  phalanx  itself,  the  site  of  the 
primary  injury,  would  show  little  or  no  serious  conse- 


FlG.  122. — Lymphatics  about  one  of  the  palmar  flexion  creases.     (After 

Sappey.) 

quences.     This  wdll  be  discussed  more  fully  under  sympto- 
matology. 

If  the  deep  lymphatics  are  involved,  the  course  naturally 
follows  the  course  of  the  veins,  as  has  been  pointed  out 
above.  If  localized  abscesses  develop,  they  appear  along 
the  line  of  these  vessels.  If  it  be  the  interosseous,  the 
abscesses  will  naturally  lie  under  the  flexor  profundus, 


SPOROTRICHOSIS  317 

thus  occupying  the  site  I  have  already  ])ointed  out  as 
that  in  which  the  deep  abscesses  spreading  from  the 
tendon  sheaths  are  always  found.  In  these  cases  doubt- 
less the  tendon  sheaths  would  be  involved  early,  and  then 
we  would  have  a  typical  tendon-sheath  infection. 

If  the  lymphatic  vessels  along  the  radial  and  ulnar 
vessels  are  the  source,  the  abscesses  will  naturally  lie 
along  these  vessels.  It  has  not  been  my  experience  to 
meet  with  any  such  cases,  and  I  am  inclined  to  believe 
that  their  occurrence  is  uncommon.  I  have  seen  abscesses 
along  the  brachial  vessels,  however.  In  one  case  it 
developed  as  an  extension  from  a  deep  infection  of  the 
forearm,  and  in  another  as  the  sequel  of  a  typical  super- 
ficial l3'mphangitis  of  the  forearm.  It  seemed  to  me 
reasonable  in  this  latter  case  to  ascribe  its  development 
to  suppuration  in  a  lymphatic  gland  lying  in  juxtaposition 
to  the  vessel,  since  we  know  that,  while  these  glands 
ordinarily  lie  at  the  elbow  and  axilla,  they  may  occur  at 
any  part  of  the  lymphatic  stream.  From  the  very  nature 
of  the  cases  we  would  expect  deep  lymphatic  abscesses  to 
be  uncommon. 

SPOROTRICHOSIS. 

Certain  cases  in  which  nodules  develop  along  the 
lines  of  the  lymphatics,  giving  rise  to  small  abscess 
formation,  may  cause  confusion  in  that  it  is  possible  for 
us  to  have  in  traumatic  injuries  of  the  hand  an  infection 
by  sporotrichosis.  Practically  all  of  these  infections 
follow  open  wounds.     It  is  first  described  by  Schenck. 

The  disease  seems  fairly  prevalent  in  rural  districts. 
It  is  possible  that  some  of  the  cases  have  been  diagnosti- 
cated as  tuberculous  lymphangitis.  The  organism  con- 
sists of  a  branching  septate,  coarse  mycelium  from  which 
ovoid  bodies  develop  by  budding,  either  from  lateral  or 
terminal  filaments  or  from  the  sides  of  the  threads. 
These  ovoid  bodies  are  spores. 


318  LYMPHAXGiriS 

The  condition  is  characterized  by  the  history  of  a 
traumatic  injury,  and  is  accompanied  by  the  development 
of  one  or  more  sharply  circumscribed,  painless  or  sub- 
cutaneous abscesses  along  the  course  of  the  lymphatic. 
Inflammatory  manifestations  are  generally  absent.  The 
course  is  extremely  chronic,  lasting  for  a  number  of  weeks. 

The  treatment  consists  in  thoroughly  opening  the 
abscesses,  cleansing  them,  and  giving  large  doses  of 
potassium  iodide  internally. 

RELATIONS  OF  LYMPHATIC  ABSCESSES  STUDIED  BY 
EXPERIMENTAL  INJECTIONS. 

In  order  to  study  the  subject,  attempts  were  made  to 
inject  masses  from  given  sites  along  the  vessels  in  cadaver 
hands.  The  results  did  not  add  much  to  our  knowledge, 
but  I  will  summarize  them  here. 

Report  of  Injections  of  Forearm  near  the  Radial 
AND  Ulnar  Vessels. — Experiment  i. — Cannula  passed 
through  small  incision  superficial  to  the  radial  vessels 
just  above  the  wrist.  The  mass  was  injected  with 
considerable  force,  and  on  examination  a  superficial 
area  three  inches  in  length  and  one  inch  in  diameter  was 
found  filled  with  the  injected  mass.  (Note. — It  is 
extremely  difficult  in  injecting  the  cannula  to  know  just 
exactly  the  position  it  occupies.) 

Experiment  2.  —  Injected  posteriorly,  i.  e.,  dorsal  to 
the  radial  vessels.  The  mass  spread  upward,  and  in  the 
section  was  found  to  lie  on  the  radial  side  of  the  flexor 
longus  pollicis,  tearing  the  muscle  to  a  great  extent  up 
to  its  origin.  The  mavSS  had  extended  to  the  ulnar  side 
of  this  vessel,  a  small  part  of  it  lying  on  the  radial  side 
between  the  bodies  of  the  flexor  profundus  digitorum  and 
flexor  sublimis  digitorum.  The  greater  portion  had 
passed  underneath  the  flexor  profundus  digitorum  and 
filled  up  the  area  between  this  muscle  and  the  bones  with 
the   interosseous   membrane.     It   had    extended    to   the 


LYMPHATIC  ABSCESSES  319 

ulnar  side,  lyinc,  in  juxtaposition  to  the  flexor  carpi 
ulnaris,  and  at  its  distal  end  came  to  lie  near  the  surface, 
i.  c,  near  the  ulnar  vessels.  It  had  extended  distally 
between  the  tendons  of  the  flexor  profundus  digitorum 
and  the  pronator  quadratus.  It  did  not  pass  into  the 
hand.  It  has  extended  en  masse  approximately  to  about 
three  inches  below  the  elbow-joint,  and  a  small  prolonga- 
tion or  isthmus  extended  along  the  median  nerve  above 
the  elbow-joint  for  three  or  four  inches  into  the  arm,  still 
lying"  close  to  the  median  nerve  and  consequently  near 
the  brachial  vessels  and  accompanying  nerves.  (Note. — 
Out  of  six  injections  more  or  less  satisfactory,  this  exten- 
sion occurred  in  two  cases,  suggesting  why  it  is  that  in 
deep  infections  of  the  forearm,  loss  of  function  of  the 
muscles  is  so  uncommon,  since  both  the  blood  supply 
and  the  nerve  supply  are  impaired.) 

Experiment  3. — Results  practically  the  same  as  Experi- 
ment 2. 

Experiment  4. ^Results  practically  the  same  as  Experi- 
ment I. 

Experiment  5. — Mass  lay  to  the  radial  side  of  the  arm 
above  the  flexor  longus  poUicis  and  to  the  radial  side  of  the 
flexor  profundus  digitorum. 

General  Conclusions  in  this  Series  of  Experi- 
ments UPON  THE  Radial  Vessels. — We  have  demon- 
strated that  if  an  abscess  should  develop  along  the  course 
of  the  lymphatic  vessels,  lying  in  juxtaposition  to  the 
radial  artery,  it  may  be  a  superficial  abscess  which  would 
point  on  the  radial  side  of  the  arm.  If  it  follows  the 
vessels  farther  it  may  spread  to  the  deep  tissues  of  the 
arm.  In  other  words,  it  may  produce  the  same  result 
as  an  extension  along  the  interosseous  vessels  or  a  rupture 
from  the  ulnar  or  the  radial  synovial  sheaths.  It  may 
extend  to  the  ulnar  side  and  lie  immediately  under  the 
skin. 


320  LYMPIIAAG/T/S 

Experiments  by  Injection  along  the  Ulnar  Artery. 

- — As  in  the  injections  along  the  radial  artery,  these 
experiments  are  more  or  less  unsatisfactory  owing  to  the 
fact  that  there  was  always  considerable  doubt  as  to  the 
exact  position  the  tij)  of  the  cannula  occupied,  although 
the  intention  was  to  inject  as  close  to  the  ulnar  artery  as 
possible,  i.  e.,  to  simulate  the  origin  of  a  large  abscess 
coming  from  the  lymphatics  and  lying  in  juxtaposition  to 
this  vessel. 

In  this  series  five  injections  were  made  at  various  sites, 
and  demonstrated  the  tendency  of  such  accumulations 
to  come  to  the  surface  on  the  ulnar  side  early  in  the 
course.  If  the  injection  was  persisted  in,  the  area  of  the 
forearm  involved  was  first  that  between  the  flexor  carpi 
ulnaris  and  the  flexor  profundus  digitorum;  then  between 
the  superficial  and  deep  flexors,  and  then  the  area  between 
the  deep  flexor  and  the  bone,  i.  e.,  the  typical  deep  abscess 
of  the  forearm. 

the  pathology  of  lymphangitis. 

The  pathology  of  these  cases  concerns  itself  particularly 
with  the  changes  in  the  lymphvessels  and  glands,  and 
need  not  be  discussed  in  completeness,  since  the  general 
facts  are  well  known.  A  picture  of  the  condition  found  in 
a  typical  case  will  be  as  follows: 

The  local  changes  at  the  site  of  injury  may  be  so 
insignificant  as  to  escape  notice.  The  local  reaction, 
even  in  a  case  that  threatens  lethal  issue,  may  be  nothing 
more  than  a  slight  redness  indicative  of  a  hyperemia. 
There  is  no  hardness  suggestive  of  the  outpouring  of  the 
protective  leukocytes  with  the  coagulation  of  the  lymph 
and  blood  elements  about  a  site  of  injury  and  infection, 
as  is  seen  in  the  localized  staphylococcus  infection, 
eilthough  great  pain  may  be  present.  This  is  jiarticularly 
seen  in  the  distal  phalanx,  where  the  differential  diagnosis 
between  this  condition  and  a  beginning  felon  must  be 
made. 


THE  PATHOLOGY  OF  LYMPHANGITIS  321 

The  lymphatic  vessels  show  grossly  by  their  redness 
the  hyperemia  surrounding  them,  and  a  microscoi)ic 
examination  shows  the  destruction  of  the  endothelium 
suggesting  a  virulent  poison  or  great  activity  in  over- 
coming the  bacteria.  Adami  has  emphasized  the  import- 
ant part  the  endothelial  cells  play  in  inflammations,  in 
that  they  may  act  as  phagocytes  and  may  undergo 
changes  to  giant  cells  or  other  forms  more  fitted  to  combat 
the  process.  A  cross-section  will  show  these  changes, 
and  in  addition  may  show  the  vessels  filled  by  a  thrombus 
made  up  of  cells  and  bacteria,  and  in  those  cases  where 
the  thrombus  lies  close  to  the  wall  the  bacteria  may  be 
seen  in  that  also.  If  the  vessel  is  injured  or  cut,  the 
bacteria  spread  beyond  the  wall,  but  in  the  ordinary  simple 
case  they  will  be  found  confined  to  the  wall  and  the 
lumen.  The  bacteria  do  not  seem  to  be  in  the  leukocytes 
to  any  great  extent,  but  they  are  so  mixed  together  in  the 
thrombus  as  to  leave  some  doubt  in  my  mind  on  this 
point.  At  some  points  I  have  found  the  thrombus 
entirely  free  from  bacteria,  in  which  case  it  may  be 
reasoned  that  the  toxin  has  produced  the  thrombus  in 
advance  of  bacterial  extension.  In  some  instances,  in 
spite  of  the  changes  in  the  lumen,  the  vessel  wall  showed 
little  change.  The  endothelium  was  not  changed.  There 
were  no  endothelium  giant  cells.  The  connective  tissue 
about  showed  the  evidences  of  inflammation  with  moder- 
ate round-celled  infiltration,  although  this  did  not  extend 
far  into  the  adjacent  areas.  The  capillaries  were  engorged 
with  blood  for  some  distance,  and  the  connective-tissue 
fibers  were  separated  by  the  serous  exudate.  If  the 
inflammation  is  a  chronic  one,  all  of  the  changes  incident 
to  such  infection  are  seen.  If  the  vessel  is  cut,  there  is  a 
rapid  extension  to  the  surrounding  tissue,  which  macro- 
scopically  takes  on  the  appearance  of  an  erysipelas  and 
pathologically  shows  the  inflammatory  changes  associated 
with  it.     About  the  lacunae  the  changes  I  have  just  des- 


322  LYMPHANGiriS 

cribed  are  most  marked,  a  much  wider  area  about  them 
beini?  involved. 

The  lymph  glands  show  nothing  different  from  the 
ordinary  picture  seen  in  varying  inflammations  of  their 
structure.  Systemically  in  severe  cases  marked  changes 
in  the  blood  and  various  organs  are  found  which  will 
be  discussed  when  speaking  of  the  fatal  cases. 

In  the  severe  cases  locally  we  may  find  that  the 
subcutaneous  tissue  and  even  the  skin  may  become 
gangrenous.  Of  course  the  former  is  most  common. 
Here  the  abscess  will  form,  and  when  opened  large 
sloughs  of  connective  tissue  may  be  removed  from  which 
the  streptococcus  may  be  secured  in  pure  culture. 

Resum6. 

The  source  of  lymphangitis  is  frequently  an  injury  so 
slight  as  not  to  be  recognized  or  remembered  by  the 
patient.  It  is  probable  that  in  the  majority  of  cases 
the  organism  at  fault  is  the  streptococcus,  but  various 
pathological  organisms  may  be  found. 

Gonorrheal  lymphangitis  occurs  as  a  result  of  systemic 
infection. 

While  hemolysis  is  often  a  marked  accompaniment 
of  streptococcus  lymphangitis,  it  is  not  necessarily 
present.  In  very  severe  types  of  infection  the  effect  of 
symbiosis  is  not  definitely  determined. 

The  lymphatics  pursue  the  shortest  course  to  the 
back  of  the  hand,  consequently  infection  at  the  distal 
portion  of  the  palm  will  spread  around  the  web  into  the 
dorsum.  In  case  of  local  infection  in  the  palm  the 
swelling  of  the  dorsum,  due  to  edema,  may  be  very  great, 
even  greater  than  on  the  palm.  Care  should  be  exercised 
not  to  incise  on  the  dorsum  but  in  the  palm  in  such  cases. 

Small  areas  along  the  inflamed  lymphatic,  the  size  of 
a   small   pea,    which   appear   red    and    swollen,    indicate 


LYMPHANGITIS  \\2'^ 

lacunae  in  the  course  of  the  vessels  and  are  not  an  evidence 
of  localized  infection  and  should  not  he  incised. 

The  little  finger  and  ring  finger  drain  into  the  epitroch- 
lear  glands  and  then  to  the  axillary.  A  small  percentage 
of  infections  beginning  in  the  middle  finger  pass  directly 
up  over  the  clavicle  and  into  the  subclavian  glands  with- 
out passing  through  either  the  epitrochlear  or  axillary 
glands.  The  thumb  and  index  finger  drain  into  the  axil- 
lary glands. 

Deep  lymphatic  abscesses  are  uncommon. 

Sporotrichosis  may  be  seen  and  should  be  differentiated 
from  tuberculous  and  other  chronic  processes. 

Abscesses  following  the  deep  lymphatics  will  lie  along 
the  vessels.  If  one  develops  along  the  radial  artery, 
it  will  appear  on  the  radial  side  of  the  arm  in  the  lower 
third.  If  the  abscess  extends  upward,  it  will  enter  the 
deeper  portion  of  the  arm  and  will  become  a  submuscular 
abscess.  If  along  the  ulnar  vessel,  the  pus  will  readily 
come  to  the  surface  between  the  flexor  carpi  ulnaris 
and  the  flexor  sublimis  digitorum. 

The  pathological  change  in  the  lymphatic  vessels  is 
that  observed  in  any  inflammation. 

In  an  exceptionally  severe  case,  marked  sloughing  of 
the  entire  subcutaneous  tissue  may  occur. 


CHAPTKR   XXI. 
SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS. 

SYMPTOMS  AND  SIGNS  IN  GENERAL. 

A  PATIENT  with  a  lymphangitis  ordinarily  gives  a  history 
of  a  slight  abrasion  or  pin  prick,  which  had  been  con- 
sidered of  no  importance.  Frequently  no  history  of 
injury  can  be  secured.  The  patient  has  noticed  a  slight 
malaise  or  chilly  sensations,  possibly  a  severe  chill  may 
be  noted.  There  may  be  no  local  pain  in  the  hand  or 
arm  and  no  swelling.  Generally,  however,  there  is  slight 
sw^elling  accompanied  b^^  a  dull  pain,  and  at  times  the 
edema  on  the  dorsum  may  become  marked  and  the  pain 
very  severe.  The  symptoms  and  signs  bring  the  patient 
to  the  physician,  who  finds  in  addition  to  the  local  con- 
dition a  red  line  running  up  the  forearm  and  arm  corre- 
sponding to  the  anatomical  distribution  of  the  lymphatic 
vessels  draining  the  area  of  primary  infection.  There 
may  or  may  not  be  tenderness  or  swelling  in  the  region  of 
the  epitrochlear  or  axillary  glands.  Generally,  however, 
after  the  infection  has  lasted  twenty-four  hours  some  ten- 
derness and  swelling  are  found.  The  arm  as  a  whole 
may  show  some  slight  swelling,  although  this  is  generally 
absent. 

The  degree  of  systemic  involvement  varies  in  the 
widest  limits.  In  some  cases,  even  early  in  the  course, 
the  patient  will  present  the  evidences  of  severe  toxemia 
with  a  chill  and  high  or  low  temperature,  headache 
anorexia,  and  prostration.  In  a  majority  of  cases, 
however,  these  severe  symptoms  are  delayed  two  or  three 
days,  even  though  there  may  be  a  severe  onset  with  a 
chill,  temperature,  and  headache. 


TYPES  :^2o 


TYPES. 


Four  types  ma\-  be  seen. 

Type  I.  Simple  Acute  Lymphanc.itis. — If  the  process 
subsides,  the  ])h\sician  ina\-  be  surprised  at  the  rapid 
disappearance  of  all  evidences  of  the  infection  ])oth 
systemic  and  local.  All  objective  evidences  may  entirely 
disappear  in  from  twenty-four  to  forty-eight  hours.  The 
red  line  of  hinphatic  inflammation  may  disappear  o\-er- 
night  with  slight  tenderness  over  the  gland  area  persisting 
for  a  few  hours  longer. 

Type  II. — ^.Acute  Lymphaxgitis  with  Minor  Local 
Complications. — In  a  second  group  the  symptoms  ma>- 
subside  more  slowly  and  end  in  a  delayed  resolution  or 
even  abscess  at  the  site  of  inoculation  or  in  the  gland  area 
accompanied  by  mild  systemic  symptoms. 

Type  III.  Acute  Ly'mphangitis  with  Serious  Local 
Complications. — In  a  third  group  of  cases  complications 
arise  ending  in  tenosynovitis  or  subcutaneous  abscesses. 
These  cases  are  accompanied  by  severe  pain  early  in  the 
course  and  symptoms  more  or  less  grave  which  arouse  the 
anxiety  of  the  physician,  first,  as  to  the  possibility  of 
early  death  from  systemic  infection,  and  later,  on  account 
of  the  toxemia  associated  with  the  local  process,  which 
heals  slowh'  and  threatens  the  life  of  the  patient  or  raises 
the  question  as  to  the  necessity  for  amputation. 

Ty"pe  I\'.  Acute  Ly'mPhangitis  wtth  Sy'Stemic  In- 
volvement.— In  a  fourth  group  the  process  may  give 
rise  at  once  to  most  alarming  systemic  symptoms  and  with 
or  without  local  difficulty  end  fatally  in  a  few  days. 

The  first  and  second  groups  are  easily  classified  and 
understood. 


326       sy}rPTO}rs  .wn  srcxs  of  Ly\Tpn.\XGTTis 

ACUTE  LYMP1IAN(;1T1S  WITH  SKRIOUS  LOCAL 
COMPLICATIONS. 

The  third  type  may  be  a  constant  source  of  anxiety, 
and  the  surgeon  is  often  in  doubt  as  to  the  abihty  of 
the  patient's  resistance  to  cope  with  the  infection,  and 
he  is  constantly  questioning  the  correctness  of  his  diagnosis 
as  to  the  position  of  pockets  of  pus  and  the  adequacy  of 
his  treatment.  It  may  clear  up  the  picture  somewhat 
to  illustrate  this  by  one  or  two  examples. 

Case  XVIII. — A  patient,  Mr.  L.  W.,  was  seen  by  me  on 
the  second  day  of  his  infection.  He  had  injured  the  fore- 
finger of  his  left  hand  with  a  piece  of  fine,  rusty  wire  which 
had  penetrated  the  distal  phalanx  upon  the  volar  surface. 
He  was  complaining  of  severe  pain  in  the  entire  finger,  but 
most  marked  in  the  distal  phalanx.  An  examination  showed 
that  the  entire  finger  partook  of  a  pinkish  hue,  and  was  some- 
what swollen  throughout.  The  distal  phalanx,  while  the 
most  painful  and  tender,  lacked  the  induration  characteristic 
of  localized  infection.  A  red  line  ran  up  the  back  of  the  hand 
and  forearm  and  could  be  traced  to  the  axilla,  where  slightly 
tender  glands  could  be  palpated.  He  was  profoundly  ill, 
with  a  temperature  of  104°  to  106°. 

The  proper  procedure  was  considered  to  be  that  of 
applying  a  hot  boric  solution  dressing,  rest  both  local 
and  general,  eliminatives,  and  sedatives.  The  question 
immediately  arises  as  to  the  advisability  of  incising 
the  distal  phalanx.  It  seemed  to  me  that  lacking  the 
induration  suggestive  of  localized  pus,  the  incision  would 
do  little  good,  and  might  open  new  avenues  for  absorption. 
There  could  have  been  no  question  as  to  making  incisions 
at  other  points.  Upon  the  third  day  our  conservatism 
was  rewarded  by  seeing  the  pain  disappear  from  the 
distal  phalanx  as  well  as  the  red  line  of  lymphatic  involve- 
ment in  the  arm.  The  patient  now  located  and  limited 
the  tenderness  to  an  area  over  the  tendon  sheath  of  the 
index  finger.     There  was  no  increase  of  the  swelling  of 


LY Mr II .warns  with  local  complicatioxs     327 

the  distal  i)li<ilan.\.  altlKHii^h  the  fini>er  as  a  whole  had 
taken  on  the  full  a])])earance  characteristic  of  distention 
of  the  sheath  with  ]3us.  The  tendon  sheath  was  opened 
and  the  ])us  evacuated,  following  which  the  patient 
ultiniatel}-  recovered  with  a  preservation  of  the  finger. 
It  should  be  noted  that  no  incision  was  made  into  the 
distal  phalanx,  although  that  was  the  site  of  the  original 
pain  and  tenderness.  Moreover,  upon  the  second  day 
it  was  certainly  impossible  to  make  the  diagnosis  of 
tenosynovitis. 

Case  XIX. — Mr.  Geo.  \V.  applied  to  the  dispensary  of  the 
Post-Graduate  Hospital  with  a  history  of  having  had  a  small 
cut  upon  the  ulnar  side  of  the  palm.  Suddenly,  after  three 
days,  he  suffered  from  a  chill  and  felt  feverish.  The  hand 
-began  to  swell,  especially  upon  the  dorsum.  Upon  examina- 
tion the  remains  of  a  small  cut  could  be  seen  upon  the  palm, 
but  there  was  no  evidence  of  inflammation  about  it.  No 
localized  tenderness  or  swelling.  The  dorsum  of  the  hand, 
especially  upon  the  ulnar  side,  was  greatly  swollen  and 
reddish.  The  skin  of  the  entire  dorsum  was  red.  There  was 
no  subcutaneous  induration,  and  the  skin  itself,  while  red, 
did  not  ha^■e  the  brawny  induration  found  in  erysipelas.  A 
red  line  of  lymphatic  involvement  ran  up  on  the  dorsum  of 
the  forearm,  and  could  be  traced  to  the  epitrochlear  region 
and  then  along  the  inner  side  of  the  arm  to  the  axilla.  Tender 
glands  could  be  palpated  in  both  regions.  Temperature, 
103°;  pulse.  100. 

The  question  arose  whether  or  not  an  incision  should 
be  made  over  the  tender  swollen  dorsum.  It  was  reasoned 
that  this  was  not  indicated,  since  there  was  no  evidence 
of  a  localized  abscess  here  or  of  a  diffuse  phlegmon,  which 
at  times  accompanies  erysipelatous  infection  in  this 
region.  Conservative  treatment  was  therefore  instituted 
with  a  rapid  cessation  of  all  symptoms  in  the  hand  and 
lymphatic  vessels.  However,  the  tenderness  gradually 
increased  in  the  epitrochlear  region,  and  a  redness  which 
had  not  been  present  before  now  appeared.     At  the  end 


328  SYMPTOMS  AND  SIGNS  OF  LYMPH ANGTTIS 

of  seven  days  a  suppuration  which  had  liad  its  origin  in 
the  gland  here  was  diagnosticated.  Drainage  was  insti- 
tuted, with  complete  recovery  in  a  short  time. 

Phlegmonous  Lymphangitis. — One  of  the  most  serious 
types  is  that  in  which  the  infection  seems  to  involve  the 
skin  of  the  back  of  the  hand  and  forearm  like  an  erysipelas. 
The  toxemia  is  great,  the  forearm  greatly  swollen,  and  the 
board-like  skin  shows  small  blebs  or  blisters  upon  its 
surface.  The  bacteria  soon  invade  the  subcutaneous 
tissue  and  lead  to  a  destruction  of  areas  of  the  subcu- 
taneous tissue  671  masse,  thus  leaving  the  infected  skin 
without  proper  blood  supply.  Consequently,  large 
pockets  filled  with  pus  and  seminecrotic  tissue  underlie 
the  skin  of  the  dorsum,  which  itself  soon  becomes  gan- 
grenous in  spots.  Meanwhile,  the  patient  is  suffering 
from  a  severe  toxemia  or  sepsis.  The  superficial  veins 
may  become  thrombosed  and  threaten  death  by  acting 
as  the  source  of  infection,  even  though  the  lymphatic 
absorption  may  have  ceased.  The  greatest  care  should 
be  exercised  in  differentiating  this  type  from  the  swollen, 
reddened,  edematous  form  seen  in  ordinary  lymphangitis, 
in  which  there  is  no  induration  either  of  the  skin  or 
subcutaneous  tissue. 

Examples  of  these  types  could  be  multiplied  many 
times  in  my  experience.  The  early  signs  and  symptoms 
very  commonly  point  to  an  entirely  different  area  as  the 
probable  site  of  abscesses  than  the  one  in  which  it  ulti- 
mately develops,  and  I  wish  to  emphasize,  therefore,  that 
the  diagnosis  of  the  accumulation  of  pus  should  be  made 
only  upon  positive  signs.  After  once  localizing,  the 
abscesses  follow  the  definite  lines  laid  down  in  the  chap- 
ters upon  tenosynovitis  and  fascial-space  infection. 

The  Frequency  of  Localization  in  Lymphatic 
Infection. — The  frequency  with  which  localization  takes 
place  in  lymphangitis  is  hard  to  state  accurately.  In  my 
experience  lo  to  15  per  cent,  of  the  cases  would  probably 


LVMPIIAXGJTJS  WITH  SYSTEMIC  IXVOLVEMEST    329 

be  nearly  correct,  and  if  an>thini;,  it  would  be  less  rather 
than  more  than  that.  The  sites  of  such  invoKement  are 
ordinarily  the  tendon  sheaths  of  the  respecti\-e  linger, 
the  dorsum  of  the  hand,  the  dorsum  of  the  forearm,  the 
axilla,  and  the  epitrochlear  region.  Secondary  to  tendon- 
sheath  infections  and  deep  infections  of  the  hand,  it  is 
common  to  find  a  subcutaneous  accumulation  of  pus  of 
lymphatic  origin  on  the  flexor  surface  of  the  wrist.  From 
these  observations  it  is  very  evident  that  a  great  majorit}' 
of  the  cases  of  lymphangitis  subside  without  secondary 
abscesses  unless  they  are  engendered  by  ill-advised 
incisions. 

ACUTE  LYMPHANGITIS  WITH  SYSTEMIC  INVOLVEMENT. 

In  our  classification  we  have  included  in  this  group 
those  severe  infections  which  through  systemic  absorp- 
tion or  infection  threaten  or  destroy  the  life  of  the  patient 
They  may  arise  from  any  source  or  in  any  individ- 
ual. They  are  more  likely  to  occur  in  individuals  over 
thirty-five  years  of  age.  and,  if  fatal,  within  a  short  time 
are  more  inclined  to  follow  infections  of  the  thumb,  index 
or  middle  finger.  The  little  finger  is  the  origin  of  many 
fatal  cases,  but  here  the  lethal  issue  is  often  due  to  infec- 
tion through  involvement  of  the  tendon  sheaths  with 
improper  drainage.  In  other  words,  death  is  the  out- 
come of  two  types  of  infections:  (i)  An  acute  type 
without  localization  in  the  hand,  and  (2)  a  severe  type 
with  localization,  subsequent  toxemia  from  inadequate 
drainage,  and  the  inability  of  the  patient's  system  to  wall 
off  the  infection,  ending  in  death  from  exhaustion  and 
sepsis.  These  types  will  be  discussed  when  dealing  with 
systemic  infection,  and  we  shall  mention  them  only  briefly 
here  for  the  sake  of  completeness.  The  onset  is  generally 
brusque.  The  patient  suffers  a  chill,  followed  by  a  high 
temperature,  which  later  becomes  lower  as  the  toxemia 
increases.     There  is  little  local  reaction  along  the  line  of 


:VM)         SYMPTOMS  AX/)  SfCXS  OF  I.YMPIIAXCITrS 

the  lymphatic  or  other  i^landular  rci^ion.  The  ])rostra- 
tioii  is  profound,  the  headache  severe.  The  face  becomes 
pinched,  the  eyes  rovini^,  the  pulse  running,  and  the 
patient  is  restless  and  cannot  sleep.  The  prostration 
becomes  greater,  the  pulse  more  running,  the  temperature 
normal,  subnormal,  or  high,  the  skin  clammy  and  the  nose 
cold;  in  other  words,  the  typical  picture  of  a  virulent 
toxemia.  Meanwhile  the  physician  looks  on  helplessly, 
since  there  is  no  localization  which  he  may  attack. 

Deep  Lymphangitis. — The  diagnosis  of  deep  lym- 
phangitis must  often  remain  in  doubt,  since  it  is  generally 
associated  with  a  superficial  inflammation,  at  times 
showing  red  lymphatic  lines,  but  generally  appearing  as 
of  the  erysipelatous  type.  The  whole  arm  and  forearm 
are  swollen  as  if  the  extremity  were  a  sac  and  the  whole 
filled  with  fluid.  It  will  be  noted  that  this  is  different 
from  the  appearance  in  superficial  lymphangitis,  in  which 
the  back  of  the  forearm  is  swollen  out  of  proportion  to  the 
front.  There  is  tenderness  early  throughout,  but  most 
marked  on  the  dorsum,  where  the  superficial  lymphatics 
are  acutely  inflamed.  The  patient  is  generally  profoundly 
ill  with  all  the  evidences  of  toxemia.  In  no  case  that  I 
have  had  has  there  been  any  localization  of  pus  about 
the  deeper  portion  of  the  arm.  In  one  patient  an  abscess 
localized  itself  along  the  radial  artery  about  two  inches 
above  the  wrist.  This  was  subsequently  drained,  with 
recovery  of  the  patient.  I  have  not  seen  any  cases  which 
could  not  be  explained  on  the  assumption  of  an  extension 
from  a  ruptured  tendon  sheath,  although  it  is  certain  they 
are  possible. 

A  fatal  case  of  deep  lymphangitis  came  under  my 
notice  a  short  time  ago,  in  which  the  patient  made  a 
primary  recovery,  but  died  after  four  w^eeks  from  a 
pneumonia,  probably  directly  dependent  upon  the 
primary  infection.  Indeed,  these  serious  cases  of  infec- 
tion frequently  come  to  a  fatal  issue  because  of  some 


LYMrilAXGITlS   WITH  SYSTEMIC  IXVOLVEMESr   :«1 

intercurrenl  c-oniplicalion,  and  such  slicHild  always  be 
looked  lor  and  liuarded  as^ainst.  A  brief  resume  of  the 
case  will  eni])hasize  the  clinical  picture. 

Case  XX, — Mr.  J.  R.  D.  (Fig.  123),  an  employee  of  the 
customs  house,  bruised  the  thumb  of  his  left  hand  in  getting 
off  a  street  car.  As  he  expressed  it,  he  thought  that  he  had 
dislocated  the  thumb.  There  was  some  primary  swelling. 
At  the  end  of  the  third  day  there  was  a  considerable  increase 
of  the  swelling,  so  that  the  whole  thenar  area  was  involved, 
and  the  forearm  also  began  to  increase  in  size.     He  now  con- 


FiG.  123. — Photograph  of  the  hand  of  a  patient  with  a  deep  lymphangitis 
(phlegmonous  erysipelas).     (See  Case  XX.) 

suited  Dr.  J.J.  Cole,  with  whom  I  saw  the  patient  in  consulta- 
tion. The  swelling  of  the  thenar  area  was  so  great  as  to 
suggest  the  ballooning  out  seen  in  the  abscess  of  the  thenar 
space.  The  swelling  was  distinctly  an  edema,  however,  there 
being  no  hardness  present.  It  was  treated  by  hot  boric 
dressings.  \Vithin  a  few  hours  the  whole  arm  was  swollen 
and  edematous,  as  much  upon  its  flexor  as  its  dorsal  surface, 
although  the  dorsum  showed  some  redness  which  was  not 
present  on  the  flexor  surface.  Deep  tenderness  could  be 
elicited  on  both  surfaces,  especially  over  the  radial  side.  By 
the  end  of  the  third  day  the  swelling  of  the  arm  had  subsided 


332         SYMPTO}rS  A XI)  SfGXS  OF  LYMPH. WGITTS 

to  a  considrraMc  cxtciil.  and  the  swcllinj^  of  the  llcxor  surface 
of  the  forearm  was  (iistincth'  less.  The  dorsiim,  ho\ve\er, 
was  still  swollen,  ha\"ini;  tlu'  appearance  and  ^i^ix  in^  the  same 
sense  of  hardness  on  palpation  as  noted  in  erysipelas.  Incis- 
ions made  upon  the  dorsum  showed  that  the  subcutaneous 
connective  tissue  was  necrotic  en  masse  and  could  he  removed 
with  the  forceps.  The  whole  dorsum  of  the  forearm  was  under- 
mined. Several  incisions  were  made  which  drained  satis- 
factorily. Owung  to  the  large  flaps  of  skin  left  without  blood 
supply,  in  which  the  \itality  was  impaired  by  the  infection, 
some  areas  of  this  also  sloughed.  As  the  process  subsided 
the  thrombosed  superficial  veins  could  l)e  seen  on  the  surface 
of  the  deep  fascia.  The  patient  made  a  rapid  primary 
recovery,  so  that  he  left  the  hospital  at  the  end  of  eight  days. 
The  local  process,  however,  had  not  entirely  healed.  Some 
slight  toxemia  was  present,  from  which  the  patient  was 
slowly  recovering,  when  he  was  suddenly  overtaken  by  a 
pneumonia  at  the  end  of  four  weeks,  and  died  after  three 
days.  A  culture  taken  from  a  bleb  which  had  formed  upon 
the  skin  showed  a  staphylococcus  infection.  In  the  subcu- 
taneous pus,  however,  a  pure  culture  of  Streptococcus  pyo- 
genes was  found,  and  I  believe  that  to  have  been  the  source 
of  the  infection.  Unfortunately, j^no  postmortem  could  'be 
secured. 

Incidentally,  this  finding  of  the  staphylococcus  under 
the  epidermis,  when  the  real  cause  was  a  streptococcus, 
emphasizes  the  error,  which  is  common,  of  mistaking 
the  local  subepidermal  infection  for  the  primary  cause 
when  it  may  be  really  secondary. 

Systemic  Involvement. — As  a  sequence  of  lymphan- 
gitis proper  or  associated  with  other  types  of  infection  of 
the  hand,  systemic  involvement  may  be  seen.  It  occurs 
more  frequently  as  the  age  increases.  While  deaths 
may  occur  at  any  age,  by  far  the  greatest  number  occur 
after  forty-five  years,  and  after  fifty  years  a  severe  infec- 
tion of  the  hand  should  be  looked  upon  with  anxiety. 
It  occurs  most  often  associated  with  a  streptococcus  infec- 
tion.    In  one  case,  however,  that  died  under  my  care,  a 


L  YMPHA  NGl  1  IS  1 17  Til  S  YSTKM IC  IN  VOL  VKM EN  1 '    'Mi'.i 

staphylococcus  was  ])resent  in  the  pus  of  the  ])rimary 
abscess  (Case  XXI).  Every  case  showing  evidence  of 
septicemia  should  be  regarded  as  extremely  grave.  Early 
in  the  course  it  may  be  impossible  to  differentiate  a  septi- 
cemia from  a  toxemia,  since  they  will  present  the  same 
picture  at  the  onset.  The  temperature  is  often  103°  to 
106°;  the  pulse,  120  to  130.  The  dry  tongue  and  skin; 
the  restless,  roving  eyes;  the  constantly  moving  limbs; 
the  thirst;  scanty  urine;  headache;  sleeplessness;  flushed 
cheek;  damp  brow;  and  the  quivering  nostril,  with  the 
history  of  chilly  feelings  or  a  chill,  present  a  picture 
known  to  all,  and  early  may  be  present  in  either  a  toxemia 
or  a  septicemia.  In  a  toxemia,  however,  all  these  symp- 
toms should  subside  within  three  days  if  due  to  a  primary 
unopened  lymphangitis,  or  if  it  follows  the  opening  of  an 
abscess  or  a  tenosynovitis.  If,  instead  of  subsiding,  the 
symptoms  grow  more  severe,  it  is  probable  a  systemic 
infection  is  present  if  the  local  pockets  of  infection  have 
been  drained.  The  temperature  generally  continues 
high  until  death,  but  may  become  remittent,  showing 
chills  from  time  to  time  or  symptoms  and  signs  incident 
to  complications,  such  as  bronchitis,  pneumonia,  pleurisy, 
lung  abscess,  metastatic  abscesses,  and  tenosynovitis, 
especially  of  the  extensor  tendon  of  the  great  toe,  in  my 
experience.  The  eye  muscles  may  become  paralyzed 
(Tornier).  Almost  all  cases  die  when  these  severe 
symptoms  develop.  Death  comes  on  with  the  patient 
in  coma  or  delirium.  Should  the  patient  recover,  the 
evidences  of  toxemia  gradually  subside  and  the  local 
wound  begins  to  show  evidences  of  repair.  The  condition 
of  the  local  wound  as  to  repair  is  of  considerable  prognostic 
importance.  When  a  wound  does  not  heal  as  rapidly 
as  it  should  after  opening,  exceptional  care  as  to  the 
systemic  treatment  should  be  used. 

A  fatal  case  following  a  simple  middle  palmar  abscess 
which  had  been  undiagnosticated was  referred  to  me  and 


334         SYMPTOMS  AM)  S/G\S  OF  LY M PIl AXGITTS 

is  worth  reporting,  since  it  illustrates  the  picture  in  the 
septic  cases. 

Case  XXI. — Air.  R.  K.,  aged  sixty-five  years,  admitted 
to  the  hospital  January  23,  1909.     Died,  February  i,  1909. 

The  history  as  recorded  is  very  meager.  He  stated  that  he 
hurt  his  hand  rubbing  meat  and  getting  some  brine  in  the 
vscratches  about  a  month  previous  to  entrance,  December  22, 
1908.  Following  this  his  hand  became  swollen  and  painful. 
Several  incisions  had  been  made  on  the  dorsum.  On  examina- 
tion the  right  hand  was  found  to  be  swollen,  with  the  palm 
bulging.  The  fingers  were  slightly  restricted  in  motion. 
There  was  little  restriction  of  motion  at  the  wrist,  and  little 
swelling  of  the  forearm.  Systemically  the  patient  showed 
the  results  of  toxemia,  being  pale,  weak,  and  emaciated,  with 
the  hunted  look  characteristic  of  these  cases.  The  urine 
showed  a  specific  gravity  of  1.020,  was  scanty  in  amount,  but 
contained  no  albumin.  There  were,  howe\er,  many  hyaline 
and  granular  casts,  both  broad  and  narrow.  A  diagnosis  of  a 
middle  palmar  abscess  was  made,  associated  with  a  toxemia 
of  a  high  grade,  or  sepsis,  and  in  addition  a  nephritis. 

In  view  of  these  findings  and  the  man's  age,  a  poor  prog- 
nosis was  gi\'en.  Operation:  lender  nitrous  oxide  anesthesia, 
a  Bier  constrictor  was  applied  and  about  a  half-pint  of  thick, 
creamy  pus  was  evacuated  from  the  middle  palmar  space. 
There  was  no  pus  in  the  thenar  space  or  the  tendon  sheaths. 

Following  the  operation  the  temperature  varied  from  99°  to 
101°;  pulse,  84  to  100.  During  the  second  day  it  is  noted  on 
the  history  sheet:  "Patient  removed  Bier  constrictor  during 
night,  has  involuntary  urination.  Hand  and  forearm  vio- 
lently inflamed,  arm  not  involved.  Am  not  sure  whether 
mental  symptoms  are  due  to  kidneys  or  hand." 

That  night  the  temperature  rose  to  102°,  but  varied  from 
this  to  normal  during  the  next  day.  The  pulse  averaged  100. 
During  the  fourth  day  the  temperature  ^•aried  from  normal 
to  100°.  The  pulse  was  still  not  rapid,  although  the  patient 
was  delirious  and  there  was  evidently  a  metastatic  infection 
in  the  tendon  sheath  of  the  extensor  hallucis  of  right  leg. 
Operation,  January  29,  1909.  Incision  in  palm  enlarged  and 
incision  on  lateral  surface  of  forearm  to  secure  drainage. 
Considerable  pus  evacuated.  Incision  over  right  fibula  near 
ankle  and  into  tendon  sheath  of  extensor  hallucis.  Watery 
pus  e\acuated. 


LYMriIA.\GlTIS   WITH  SYSTEMIC  LWVLVEMEM'    :«5 

The  pulse  and  temix-ratiire  ran  about  the  same  as  before. 
The  highest  pulse  recorded  is  120,  and  the  highest  tempera- 
ture, 101.4°.  ^  he  mental  condition  grew  worse,  and  the 
patient  died  two  days  later. 

Another  fatal  case,  which  I  saw  in  consultation  with 
Dr.  A.  B.  Eustace,  to  whom  I  am  indebted  for  the  history 
and  report  of  the  findings  at  postmortem,  at  which  I  was 
permitted  to  be  present  through  the  courtesy  of  Dr.  \V.  H. 
Hunter  and  Dr.  Eustace,  is  a  very  valuable  one,  since  the 
positions  of  pus  shown  at  the  postmortem  fully  corrobor- 
ate the  findings  which  I  have  noted  clinically  in  the  cases 
which  recovered,  as  w^ell  as  verify  the  results  which  I 
obtained  experimentally  by  injections  of  the  forearm.  It 
emphasizes  also  the  difficulty  of  differentiating  these 
cases  at  times  from  rheumatism.  Unfortunately,  I  have 
not  the  exact  age,  but  the  patient  was  in  the  neighborhood 
of  fifty  years,  which  again  draws  attention  to  the  influence 
of  age  in  these  fatahties. 

Here  the  primary  focus  was  in  the  ulnar  bursa.  Owing 
to  the  difficulty  of  diagnosis,  the  diagnosis  and,  conse- 
quently, the  proper  treatment  were  held  in  abeyance 
several  days. 

Case  XXII. — Miss  E.  J.,  Cook  County  Hospital.  Patient 
entered  on  June  i,  1908.  Attending  surgeon.  Dr.  E.  Wyilys 
Andrews;  house  physicians,  Drs.  Eustace  and  Courtenay. 

History  of  Present  Trouble:  Patient  enters  hospital  com- 
plaining of  pain  and  swelling  in  right  wrist  and  hand.  Upon 
questioning  she  says  she  awoke  last  Friday  night  with  pain 
in  this  joint.  There  was  a  sense  of  heat  and  the  joint  was 
particularly  painful  on  motion.  Her  sleep  was  disturbed,  and 
by  the  next  morning  she  says  her  wrist  was  notably  swollen 
and  red.  Tenderness  was  pronounced  over  the  end  of  the 
ulna  posteriorly,  and  also  anteriorly  over  both  bones  of  the 
forearm  at  their  carpal  articulation. 

A  history  of  any  previous  injury,  fall,  infection,  or  arthritis 
of  any  sort  is  denied.  The  patient  also  denies  other  symptoms 
of  any  sort,  but  since  Friday  the  joint  has  become  swollen 
and  progressively  worse,  the  pain  is  agonizing,  and  there  is 
an  indefinite  historv  of  chills  and  fever. 


336         SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

Previous  Illnesses:  For  the  past  ten  years  she  has  suffered 
intermittently  from  articular  rheumatism,  and  three  weeks 
ago  she  was  a  patient  in  this  instituion  for  otitis  media  and 
discharged  after  a  period  of  two  weeks'  treatment. 

Physical  Examination:  Negative  except  as  follows:  The 
right  wrist  and  hand  are  greatly  swollen  and  inflamed,  the 
wrist  on  both  surfaces,  the  hand  on  the  posterior  surface  only. 
The  swelling  is  localized  to  the  wrist-joint  and  extends  up 
the  forearm  for  about  three  inches.  The  fingers  are  in  semi- 
flexion, and  the  slightest  movement  causes  extreme  pain. 
There  is  also  extreme  tenderness  around  the  wrist-joint, 
which  is  also  very  painful  upon  motion.  Lymphatic  involve- 
ment is  lacking,  and  apparently  there  is  no  tendon-sheath 
involvement.  No  atrium  of  infection  can  be  found,  and 
shoulder  and  elbow-joints  are  not  involved.  The  left  arm 
is  not  involved,  though  some  pain  is  elicited  on  motion  of 
shoulder.  Fingers  give  evidence  of  a  rheumatic  diathesis 
(G.  T.  Courtenay). 

Pulse.  Temperature.  Respirations. 
June  2,  1908   ....       94                          102°  24 

June  2,  1908  ....     103  102°  24 

June  2,  1908  ....     104  101°  22 

White  blood  count  on  entrance,  8200.  Patient  given  large 
doses  of  sodium  salicylate. 

Operation,  June  4,  1908.  Incision  down  to  ulnar  bursa 
and  one  above  the  anterior  annular  ligament  on  ulnar  side. 
A  hemostat  was  forced  through  to  the  radial  sid^  and  pus 
evacuated.  Gauze  drainage  and  hot  boric  dressings.  Bier's 
constrictor  applied  to  arm  (A.  B.  Eustace). 

Operation,  June  7,  1908.  Two  incisions  on  the  flexor 
surface  of  the  forearm  just  above  the  wrist-joint  and  another 
three  inches  above  this.  These  were  each  one  inch  long  and 
penetrated  to  the  flexor  tendons;  openings  connected  with 
gauze  drainage  (G.  T.  Courtenay). 

Operation,  June  15,  1908.  Incision  along  ulnar  bursa 
enlarged  and  a  large  amount  of  pus  evacuated.  Knee-joint 
aspirated  and  pus  obtained.  Two  per  cent,  solution  of 
formalin  in  glycerin  injected.  Died  June  16,  1908.  Autopsy 
by  Dr.  A.  B.  Eustace  and  Dr.  Allen  B.  Kanavel. 

Hand  and  Arm:  Extensor  surface:  On  opening  back  of 
forearm  a  small  focus  of  pus  is  found  at  junction  of  lower 
quarters  of  forearm.  This  communicates  with  incision  in 
skin  on  side.    There  was  no  pus  between  extensor  communis 


LYMPHANGITIS  WITH  SYSTEMIC  INVOLVEMENT    337 

and  deeper  tissues,  except  at  point  indicated,  and  this  pus 
extended  down  underneath  this  muscle. 

No  pus  found  subcutaneously  on  the  dorsum  of  the  hand 
except  at  the  wrist-joint,  and  this  could  he  traced  into  the 
tendon  sheath  of  the  extensor  communis  chgitorum.  The 
tendon  sheaths  of  the  extensor  radiaHs  longior  and  brevior 
also  showed  pus.  The  tendon  of  the  extensor  carpi  ulnarls 
was  free  from  pus. 

Back  of  the  sheath  of  the  extensor  communis  digitorum  is 
seen  an  opening  extending  down  to  the  carpal  bones.  Articu- 
lation between  the  carpal  bones  and  the  radius  found  to  con- 
tain a  slight  amount  of  pus.  Articulation  between  proximal 
and  distal  row  of  bones  also  contains  a  slight  amount  of  pus. 
No  pus  found  under  tendons  on  the  back  of  the  hand,  com- 
municating with  joint. 

Flexor  Surface:  Incision  found  in  median  line,  at  junction 
of  lower  and  middle  thirds  through  skin  immediately  above 
annular  ligament,  and  on  either  side  at  and  above  articular 
surface. 

Incision  on  ulnar  side  extended  upward  for  a  distance  of 
two  and  one-half  inches.  Incjsion  also  in  palm  of  hand  on 
ulnar  side  lengthwise  along  inner  edge  of  hypothenar  eminence. 
The  hand  as  a  whole  does  not  appear  to  be  greatly  swollen, 
and  some  concavity  appears  in  the  middle  of  the  palm. 

Upon  opening  the  palm  of  the  hand,  ulnar  bursa  found  to 
be  filled  with  pus  and  tendon  sheath  of  little  finger  also  filled 
^vith  pus.  Rupture  had  occurred  into  the  forearm  at  a  point 
one  and  one-half  inches  above  the  articular  surface  of  the 
wrist-joint.  Middle  palmar  space  opened  and  found  to  be 
filled  with  pus.  Thenar  space  free  from  pus.  Tendon  sheath 
of  flexor  longus  pollicis  free  from  pus.  Radial  bursa,  no  pus 
found  at  any  point.  Above  the  wTist-joint,  pus  is  found  in 
sheath  passing  up  underneath  tendons  from  midpalmar 
space. 

Foreai;m:  Pus  is  found  underneath  the  flexor  profundus 
digitorum.  Pus  extended  up  the  forearm  in  juxtaposition  to 
ulna  up  to  the  elbow  lying  immediately  on  the  ulnar. 

Pus  also  found  along  ulnar  artery  for  a  distance  of  about 
one  and  one-half  inches  at  middle  of  forearm,  but  did  not 
extend  up  to  the  elbow.  A  small  opening  is  discernible  at 
lower  end  of  ulna  connecting  joint  with  ulnar  bursa.  It 
could  not  be  determined  definitely  whether  this  opening  was 
made  by  dissection  or  was  present  before. 


338        SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

No  opening  was  demonstrable  between  wrist-joint  and 
radial  bursa. 

No  necrosis  of  bones  of  wrist-joint;  tendon  sheath  of  ring 
finger  intact;  tendon  sheath  of  middle  finger  intact;  tendon 
sheath  of  index  finger  intact.  Pus  extended  out  in  little 
finger  to  proximal  interphalangeal  joint.  Periosteum  of 
radius  and  ulna  not  destroyed.  No  pus  in  elbow-joint. 
Axillary  glands  barely  palpable. 

Heart:    No  evidence  of  pericarditis  or  adhesions. 

Pleural  Cavities:  Left,  no  adhesions;  right,  few  adhesions 
at  apex. 

Lungs:  Left,  crepitates,  no  consideration,  frothy  red 
serum  exudes,  apparently  normal;  right,  answers  above 
description. 

Liver:  Gall-bladder  distended  and  filled  with  fluid.  Liver 
is  mottled  on  cut  sections,  the  interlobular  markings  faint, 
no  evidence  of  miliary  abscesses.  Tissues  very  soft  and 
friable  and  color  is  paler  than  normal. 

Spleen:  Enlarged  in  size,  is  soft  and  friable.  Cuts  like 
butter.    Miliary  abscesses  found. 

Kidneys:  Soft  and  friable.  Capsules  strip  with  some 
difficulty  and  leave  parts  of  the  cortex.  Cortex  is  almost 
obliterated,  as  are  also  the  pyramids,  but  here  and  there  a 
distinct  outline  of  a  pyramid  may  be  found. 

Right  Knee-joint:  Filled  with  thick  yellow  pus,  small 
ecchymotic  areas  in  periosteum. 

Cultures  before  and  after  death  showed  Staphylococcus  albus. 

Microscopic  examination  of  the  various  organs  showed 
acute  parenchymatous  degeneration. 

Postmortem  Statistics. — Tournier  reports  ten  fatal 
cases  upon  which  postmortem  had  been  made.  The 
findings  were  as  follows: 

Cases. 

Acute  hyperplasia  of  spleen       .      .      .  ' 9 

Parenchymatous  nephritis 7 

Bronchopneumonia 5 

Lung  abscesses 2 

Empyema 2 

Acute  pericarditis 1 

Hemorrhagic  pleuritis 1 

Subpericardial,  subpleural  and  cecal  hemorrhages    ....  4 

Abscess  of  kidney 2 

Abscess  of  liver 2 

Thrombosis  of  veins 2 

Icterus       3 


LYMPHANGITIS  WITH  SYSTEMIC  INVOLVEMENT    339 

The  age  of  the  fatal  cases  averaged  forty-three  and 
eight-tenths  years. 

Thrombophlebitis. — Either  associated  with  lymphan- 
gitis or  as  a  distinct  process  we  may  have  thrombo- 
phlebitis. The  symptoms  and  signs  here  would  be  the 
same  as  those  occurring  with  thrombophlebitis  of  the 
leg,  where  it  is  more  common.  Generally  beginning  with 
a  localized  infection,  the  process  extends  into  a  vein.  The 
severity  of  the  symptoms  depends  upon  the  extent  of  the 
process,  varying  from  those  of  a  mild  septicemia  with 
localized  evidences  to  most  severe  toxemia,  metastatic 
abscesses,  and  death.  This  can  best  be  illustrated  by  a 
case  which  came  under  my  care  at  the  Post-Graduate 
Hospital. 


Fig.  124. — Photograph  of  a  hand  of  a  patient  with  thrombophlebitis.     Wound  is 
left  open,  as  is  seen  in  photograph.     (Case  XXIII.) 

Case  XXIII. — Mr.  L.,  aged  twenty- five  years.  Post- 
Graduate  Hospital,  March  5,  1909  (Fig.  124). 

Diagnosis. — Suppurative  phlebitis  of  veins  of  dorsum  of 
hand. 

The  patient  applied  to  the  hospital  with  a  small  infection 
upon  the  dorsum  of  the  hand,  apparently  carbuncular  in 
nature.  The  infection  had  been  present  for  four  days,  and 
was  gradually  increasing  in  size.  The  hand  was  considerably 
swollen,  and  there  was  an  area  of  swelling  and  induration 


340         SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

extending  up  the  dorsum  of  the  forearm  for  three  inches. 
Temperature,  I0l°;  pulse,  94;  urine  negative. 

Operation. — Gas  anesthesia.  A  crucial  incision  was  made 
o\er  the  area  and  an  accumulation  of  thick  pus  and  semi- 
necrotic  tissue  evacuated.  The  indurated  area  extending 
up  the  dorsum  of  the  forearm  was  found  to  he  a  large  vein 
which  was  filled  with  a  septic  thrombus.  This  was  opened 
up  for  four  inches  on  the  area,  when  a  free  regurgitation  of 
venous  blood  was  secured.  The  vessel  was  tied  and  the  wound 
left  open  (Fig.  124).    A  Bier  constrictor  was  applied. 

Following  the  operation  the  local  area  granulated  freely, 
and  rapidly  went  on  to  complete  repair.  Over  a  period 
of  four  weeks,  however,  the  patient  developed  three 
metastatic  abscesses  in  various  parts  of  the  body,  which 
w'ere  opened.  Fortunately,  none  developed  in  the  bones 
or  viscera,  at  least  so  far  as  w^as  discovered.  The  tempera- 
ture and  pulse  were  never  high,  but  still  fluctuated  with 
the  development  of  the  foci.  The  patient  ultimately 
made  a  complete  recovery. 

Resume. 

The  symptoms  and  signs  appear  as  follows:  A  red  line 
running  up  the  forearm  corresponding  to  the  anatomical 
distribution  of  the  lymphatic  vessels  draining  the  area 
of  primary  infection.  There  may  be  no  local  reaction 
and  little  swelling;  generally,  however,  there  is  slight 
swelling  accompanied  by  dull  pain.  In  the  less  severe 
cases  considerable  edema  will  develop  on  the  dorsum  and 
the  pain  will  be  very  severe.  Early  there  is  little  tender- 
ness. Generally,  after  twenty-four  hours,  tenderness 
may  develop  in  the  extremity  over  the  glands  involved, 
i.  e.,  the  epitrochlear  or  axillary. 

Systemic  symptoms  vary  in  the  widest  limits.  In 
some  cases  very  early  the  patient  presents  evidences  of 
severe  toxemia,  with  a  chill,  high  or  low  temperature, 
headache,    anorexia,    and    prostration.     Four   types   are 


SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS         341 

seen:  A,  sim])le  acute  lymphangitis:  11iis  is  a  type  with 
few  systemic  symptoms  and  a  rapid  disapi)earance  of 
lymphatic  inflammation.  B,  acute  lymphangitis  with 
minor  local  complications:  Here  the  symptoms  subside 
slowly,  ending  in  an  abscess  at  the  site  of  inoculation  or 
in  the  gland  area.  C,  acute  lymphangitis  with  serious 
local  complications:  Here  we  have  such  complications 
as  tenosynovitis  and  subcutaneous  phlegmons.  D,  acute 
lymphangitis  with  systemic  involvement:  In  this  group 
we  have  the  most  alarming  systemic  symptoms  with  little 
local  evidence  of  disease  and  a  rapidly  fatal  issue. 

Phlegmonous,  lymphangitis  is  one  of  the  most  serious 
types  of  infection  seen.  Here  we  have  profound  toxemia, 
a  greatly  swollen  forearm,  board-like  indurations  and 
blisters  on  the  skin.  The  subcutaneous  tissue  sloughs 
en  masse.  The  superficial  veins  become  thrombosed  and 
the  patient  dies  from  toxemia  or  some  of  the  severer 
complications  of  infection,  such  as  sepsis,  meningitis, 
pneumonia,  etc. 

Localization  takes  place  in  lymphangitis  in  from  lo  to 
15  per  cent,  of  the  cases.  The  sites  are  ordinarily  the 
tendon  sheaths,  dorsum  of  the  hand,  the  dorsum  of  the 
forearm,  the  epitrochlear  region,  and  the  axilla. 

Systemic  infection  is  more  likely  to  occur  in  individuals 
over  thirty-five  years  of  age  and  is  more  likely  to  follow 
infections  of  the  thumb,  index  or  little  finger,  especially 
the  middle  finger.  In  these  cases  the  onset  is  brusque 
there  is  little  local  reaction  along  the  lymphatic  or  glandu- 
lar region,  prostration  becomes  profound,  and  death 
rapidly  ensues. 

Deep  lymphangitis  is  on  the  whole  rather  a  rare  com- 
plication. If  present,  the  pus  is  found  in  the  deeper 
portions  in  the  pockets  already  enumerated. 

Thrombophelebitis  may  occur  associated  with  lymphan- 
gitis or  as  a  distinct  process. 


CHAPTER  XXII. 
PROGNOSIS  IN  LYMPHATIC  INFECTIONS. 

The  prognosis  as  to  life  in  lymphatic  infections  is 
dependent  upon  so  many  factors  over  which  we  have 
no  control  that  it  is  extremely  difficult  to  arrive  at  any 
satisfactory  statement  concerning  it.  In  Helferich's 
clinic,  in  a  series  of  nearly  200  severe  infections  of  the 
hand,  a  fatal  issue  followed  in  22  per  cent.  These  statis- 
tics comprise  all  types  of  infection  of  the  hand,  and  are 
limited  to  extensive  abscesses,  tenosynovitis,  and  severe 
lymphangitis.  This  percentage  is  certainly  high  for 
patients  in  the  ordinary  walks  of  life.  In  my  own 
experience  the  mortality  in  these  severe  cases  will  average 
about  3  or  4  per  cent. 

Of  the  factors  concerned,  of  chief  importance  is  the 
age  of  the  individual.  The  average  age  of  fatal  cases 
is  in  the  neighborhood  of  forty-five  years.  The  general 
state  of  the  patient's  resistance  is  of  importance.  For 
instance,^  in  Cook  County  Hospital,  where  the  social 
derelicts  are  found,  the  mortality  is  much  higher  than  in 
private  hospitals.  The  presence  of  nephritis  in  the 
various  forms  or  of  any  of  the  chronic  system  diseases 
has  a  marked  influence  upon  the  prognosis. 

If  the  symptoms  of  toxemia  do  not  subside  within 
three  days,  if  no  local  process  has  developed,  or  within 
two  days  after  opening  such  foci,  anxiety  should  be 
felt  for  the  patient.  Either  there  is  a  local  extension, 
or  the  patient  is  not  reacting.  The  part  affected  has 
some  influence  upon  the  prognosis.  The  presence  of  an 
infection  beginning  in  the  little  finger  or  the  thumb  causes 
fear  of  tenosynovitis  with  a  prolonged  convalescence, 
while  an  involvement  of  the  index  or  middle  finger  may 
early  lead  to  severe  systemic  symptoms.     The  type  of 


PROGNOSIS  IN  LYMPHATIC  INFECTIONS  343 

germ  in  a  given  patient  is  also  of  great  importance  from  a 
prognostic  standpoint,  since  it  is  well  known  that  the 
gravest  infections  arise  from  the  streptococcus  and 
certain  of  the  gas  bacilli.  Again,  a  brusque  onset  with 
high  temperature  and  chills  speaks  for  a  serious  infection. 

To  my  mind  the  prognosis  is  influenced  somewhat 
by  the  character  of  treatment.  If  ill-advised  and  prema- 
ture incisions  are  made  what  might  have  been  a  moderate 
infection  may  be  turned  into  a  severe  type.  Many  attempts 
have  been  made  to  secure  data  upon  which  prognosis 
may  be  made  by  an  examination  of  the  blood,  and  this  is 
of  some  general  value.  One  of  the  latest  and  most 
complete  researches  is  that  of  Zangmeister.^ 

The  first  conclusion  which  the  author  derived  from  a 
large  series  of  blood  counts  was  that  the  numeric  fluctua- 
tions of  the  single  leukocyte  form  per  cubic  centimeter 
of  blood  show  the  real  condition  of  the  patient,  but  not 
the  numerical  ratio  of  the  variety  of  forms  to  each  other. 
To  make  a  prognosis  in  streptococcus  infections  from  the 
blood  picture  it  is  important  to  know  that  the  conditions 
change  completely  after  the  first  twenty-four  hours  after 
the  infection,  and  that  the  findings  during  the  first  twenty- 
four  hours  do  not  apply  later  on. 

In  monkeys  he  found  the  following  after  the  first 
twenty-four  hours  after  infection: 

1.  In  infections  rapidly  fatal,  all  forms  of  leukocytes 
decline  quickly  in  number. 

2.  In  infections  fatal  after  a  few  days  he  found  a  tardy 
and  small  increase  of  the  mononuclear  neutrophilic  cells 
and  a  decrease  of  the  polynuclear  neutrophilic  and 
eosinophilic  cells  and  lymphocytes  in  the  first  eighteen 
hours. 

3.  In  infections  not  fatal  he  found  an  increase  of  the 
mononuclear  neutrophilic  cells  during  the  first  six  hours 
after  the  infection;  from  then  on  a  decrease.     The  poly- 

1  Monatsschrift  f.  Geb.  und  Gynak.,  Band  xxxi,  Heft  1. 


344  PROGNOSIS  IN  LYMPHATIC  INFECTIONS 

nuclear  and  eosinoi^hilic  cells  and  lym]:)h()cytes  increase 
in  number  after  the  first  six  hours. 

Therefore  good  prognostic  symptoms  are: 

(a)  An  immediate  increase  of  the  mononuclear  neu- 
trophilic cells  for  the  first  six  or  eight  hours,  with  a 
following  decline. 

(b)  An  increase  of  the  polynuclear  cells  after  six  hours, 
after  a  short  decline. 

(c)  An  increase  of  the  eosinophilic  cells  inside  the  first 
twenty-four  hours. 

(d)  An  increase  of  the  lymphocytes  in  the  first  twenty- 
four  hours. 

The  prognosis  is  bad  (i)  if  the  mononuclear  cells 
show  no  increase  or  a  decrease  in  the  first  eight  hours; 
(2)  if  there  is  a  continuous  decrease  of  the  polynuclear 
cells  and  lymphocytes. 

In  a  large  series  of  the  blood  countings  before  and 
immediately  after  operations  the  author  found  that 
these  findings  in  monkeys  are  parallel  to  those  in  man. 

After  the  first  twenty-four  hours  conditions  are  changed, 
and  the  curve  of  the  eosinophilic  cells,  of  the  lymphocytes, 
and  of  the  mononuclear  neutrophilic  cells  is  of  no  import- 
ance. A  continuous  decrease  of  the  polynuclear  cells  or 
their  remaining  stationary  is  a  bad  prognostic  sign.  In 
less  severe  infections  they  will  rapidly  or  at  least  slowly 
increase. 

His  final  conclusions  are: 

"We  are  allowed  to  make  a  good  prognosis  inside 
the  first  twenty-four  hours  after  the  infection  if  we 
find  (a)  an  immediate  increase  of  the  mononuclear 
neutrophilic  cells  with  a  slow  decrease  after  eight  hours; 
(b)  an  increase  of  the  polynuclear  cells  after  eight  hours 
after  a  small  decrease. 

"We  have  to  deal  with  a  fatal  infection  (a)  if  the 
mononuclear  cells  increase  after  the  first  twenty  hours; 
(b)   if   the   mononuclear  cells  do   not   increase  at   all   or 


PROGXOSIS  IX  LYMPHATIC  INFECTIONS  345 

decrease  ininiediatel)'  after  infection;  (c)  if  the  poly- 
nuclear  cells  decrease  constantly. 

He  made  one  blood  count  before,  one  six  to  eight  hours, 
and  one  t\\-enty  to  twenty-four  hours  after  the  operation 
respectively. 

After  t\vent\"-four  hours,  the  number  of  polynuclear 
cells  only  is  of  importance;  if  they  are  below  normal  and 
keep  on  decreasing  the  prognosis  is  bad,  and  vice  versa. 

By  injecting  a  person  with  dead  streptococci,  Zang- 
meister  was  able  to  test  the  resisting  power  of  the  person 
against  streptococcus  infection — ''Resisteur  probe."  If 
the  resisting  power  is  reduced,  the  mononuclear  cells  after 
the  injection  will  show  no  increase  or  the  increase  comes 
late;  the  polynuclear  cells  will  show  no  increase  soon  after 
the  infection,  or  a  decrease. 

What  may  be  said  regarding  the  probability  of  local 
complications?  It  is  impossible  to  arrive  at  any  just 
estimation  as  to  the  probability  of  the  development  of 
tenosynovitis  and  fascial-space  abscesses.  In  my  experi- 
ence those  patients  showing  a  brusque  onset  with  great 
pain  are  more  likely  to  have  such  complications.  The 
tenos\'novitis  is  more  likely  to  develop  from  infection 
implanted  on  the  volar  surface  of  the  distal  or  middle 
phalanx.  Local  accumulations  on  the  dorsum  of  the  web 
between  the  fingers  are  apt  to  develop  from  the  callus 
cracks  at  the  distal  portion  of  the  palm.  Dorsal  sub- 
cutaneous thenar  abscesses  appear  in  infections  of  the 
thenar  palmar  surface.  Subcutaneous  abscesses  above 
the  anterior  annular  ligament  often  occur  in  connection 
with  tenosynovitis.  Ill-advised  incision  may  determine 
the  localization  of  infection  in  various  spaces.  In  several 
patients  whom  I  have  seen  in  consultation,  I  feel  sure  that 
the  tenosynovitis  which  developed  was  directly  due  to 
the  primary  incision. 


CHAPTER   XXIII. 

THE  TREATMENT  OF  LYMPHATIC  INFECTIONS 
—GENERAL  DISCUSSION. 

The  treatment  of  lymphatic  infections  is  based  upon 
two  principles — conservatism  and  conservation.  In  no 
type  ca?i  more  harm  be  done  by  ill-advised  incisions  than  in 
this.  The  position  of  masterful  inactivity  is  most  difficult 
to  maintain,  and  yet  the  surgeon  is  constantly  aware  that 
his  tendency  to  incise  is  due  to  his  desire  "to  do  some- 
thing" rather  than  an  exact  knowledge  as  to  what  to 
do.  We  therefore  use  local  measures  designed  to  wall  off 
and  overcome  the  infection,  combined  with  procedures 
designed  to  support  the  system,  eliminate  the  toxin  and 
increase  its  resisting  powers.  In  the  ordinary  case,  until 
some  localization  is  present,  we  apply  hot,  moist  dressings, 
insist  upon  local  and  systemic  rest,  combined  with 
cathartics,  much  fluid  intake  and  sedatives,  as  the  case 
may  demand. 

DISCUSSION  OF  VARIOUS  PROCEDURES. 

Local. — Hot,  Moist  Dressings. — Many  forms  of  such 
applications  are  in  use  and  have  a  vogue  for  a  time. 
It  is  my  personal  opinion  that  such  applications  owe  their 
value  more  to  the  moist  heat  than  to  the  drug  with  which 
they  are  combined.  It  is  my  custom  to  use  boric  acid 
in  saturated  solution.  I  am  aware  that  many  studies 
have  been  made  from  which  conclusions  were  drawn  as 
to  its  antiseptic  property  when  absorbed  by  the  blood 
stream.  It  is  probable  that  it  would  be  unjust  to  say 
that  such  minute  quantities  as  have  been  demonstrated 
in  the  blood,  and  consequently  in  the  urine,  can  have  no 


TREATMENT  OF  LYMPHATIC  INFECTIONS  347 

effect,  since  no  one  knows  the  effect  of  combining  small 
proportions  of  any  chemical  solution  with  blood  serum 
in  vivo,  although  in  the  test-tube  such  combinations  may 
be  shown  to  be  without  value.  It  would  seem  more 
reasonable  to  ascribe  the  beneficial  value  of  such  applica- 
tions to  the  dilatation  of  the  capillaries  and  the  bringing 
of  more  blood  to  the  part,  favoring  the  walling-off  of  the 
infection. 

Peculiar  value  has  been  ascribed  by  various  surgeons  to 
bichloride  solution,  creolin,  almost  all  of  the  various 
antiseptics,  ichth3'ol,  alcohol,  etc.  Unless  they  are  used 
for  a  particular  purpose,  however,  it  would  seem  that  hot 
boric  acid  solution  will  be  as  efficient  as  any. 

Certain  special  purposes  may  be  secured  by  special 
solutions.  In  those  cases  in  which  there  is  a  foul  odor, 
a  I  :  2000  or  i  :  4000  potassium  permanganate  solution 
will  be  found  of  value.  We  may  secure  some  slight 
local  antiseptic  property  in  the  use  of  alcohol  dressings, 
using  a  30  to  50  per  cent,  solution.  This  should  not  be 
kept  up  any  length  of  time.  It  is  certaintly  not  neces- 
sary to  warn  the  profession  against  the  use  of  carbolic 
acid  solution  in  any  strength.  The  frequency  with  which 
carbolic  acid  gangrene  is  seen,  however,  leads  me  to  urge 
upon  physicians  the  necessity  of  informing  patients  of  the 
danger  of  this  remedy,  which  is  so  often  the  home  applica- 
tion for  all  cuts  and  injuries. 

The  method  of  applying  hot  boric  dressings  has  been 
discussed  in  Chapter  VL  They  are  so  applied  as  to  cover 
the  entire  forearm  and  arm  in  the  severe  cases.  It  is  a 
good  rule,  to  make  the  dressing  much  larger  than  the 
condition  would  seem  to  call  for.  These  hot,  moist  dress- 
ings are  to  be  used  until  the  red  line  of  lymphatic  involve- 
ment has  entirely  disappeared  and  any  acute  edema  has 
begun  to  subside,  at  which  time  a  change  should  be  made 
to  a  dry  dressing  of  some  kind. 


348  TREATMENT  OF  LYMPHATIC  IXFECTIOXS 

Rest. — Both  local  and  systemic  rest  should  be  insisted 
upon,  especially  in  severe  infections.  The  local  rest  is 
of  special  value  in  a  prophylactic  sense,  since  every 
movement  of  the  fingers  or  hand  tends  to  favor  lymphatic 
circulation  and  hence  to  favor  dissemination  of  the 
infection.  Von  Volkmann  and  others  have  advised  sus- 
pending the  arm  so  that  the  hand  is  elevated.  It  does 
not  seem  that  this  would  be  of  value  except  to  relieve  the 
pain  of  a  congestion,  and  it  has  not  seemed  to  me  to 
influence  the  course  favorably. 

The  Bier  Treatment. — The  place  of  the  Bier  treatment 
in  infections  of  the  hand  has  already  been  touched  upon 
(p.  'J 2).  In  these  lymphatic  infections  I  have  used  it  only 
in  the  same  sense  that  we  would  use  a  ligature  to  prevent 
the  rapid  absorption  of  any  poison,  as,  for  instance,  in  the 
slow  absorption  permitted  in  snake  bites.  It  therefore 
would  find  a  place  in  the  early  hours  of  a  virulent  lym- 
phatic infection  in  which  the  system  may  be  receiving 
large  doses  of  virulent  toxins  without  seeming  to  have  the 
reactive  power  necessary  to  wall-ofT  the  infection.  Here 
the  constrictor  is  applied  for  from  twelve  to  eighteen 
hours,  tight  enough  to  secure  a  marked  edema.  This  is 
done  with  the  hope  that  the  lack  of  reaction  upon  the 
part  of  the  system  is  due  in  part  to  the  fact  that  it  is  over- 
whelmed, and  that  if  small  doses  are  allowed  to  enter  the 
system  a  marked  antitoxin  will  be  developed  which  will 
be  able  to  withstand  the  toxin  if  its  entrance  into  the 
system  is  spread  over  some  time.  Whether  or  not  dia- 
pedesis  of  leukocytes  in  these  infections  is  favored  by 
passive  congestion  is  a  moot  question. 

The  method   of  applying  the   bandage   is   as   follows: 

A  Martin  bandage  two  inches  wide  is  used.  The 
bandage  is  begun  at  a  point  slightly  above  the  elbow 
and  carried  to  a  point  slightly  below  the  axilla.  Several 
turns  are  carried  about  the  arm,  so  made  as  to  preserve 
an  equable  pressure  throughout.     The  pressure  should  be 


DISCUSSION  OF  VARIOUS  PROCEDURES  349 

sufficient  to  produce  a  moderate  edema  in  an  hour,  and 
should  not  be  sufficient  to  produce  pain.  The  method 
used  by  some  of  wrapping  a  towel  about  the  arm  and 
securing  constriction  by  a  rubber  tube  or  narrow  rubber 
band  is  unwise,  since  it  will  cause  considerable  pain  and  is 
more  likely  to  produce  nerve  injury.  After  the  bandage 
has  been  in  place  twelve  to  eighteen  hours  it  is  removed 
and  replaced  in  a  couple  of  hours  if  the  toxemia  is  still 
high.  Ordinarily,  one  or  two  eighteen-hour  periods  is 
all  I  have  found  of  advantage  in  these  case.  In  later 
years  I  have  used  an  ordinary  blood-pressure  apparatus 
filling  the  arm  band  with  air  up  to  the  desired  pressure. 

Incisions. — There  may  be  some  difference  in  opinion 
as  to  the  advisability  of  incisions  under  certain  conditions. 
There  are  those  who  teach  that  an  incision  made  at  the 
point  of  great  pain  and  tenderness  when  it  is  the  site  of 
the  primary  infection  will  be  of  value.  They  maintain 
that  such  an  incision,  if  it  does  not  evacuate  pus,  favors 
drainage  about  the  site  of  the  infection,  and  that  the 
escaping  serum  carried  off  the  bacteria.  It  is  my  own 
belief  that  this  hope  is  seldom  justified,  and  that  the 
incision  simply  opens  new  lymphatics  for  infection  and 
fails  to  reach  the  bacteria  which  have  already  entered 
the  lymphatic  stream  and  are  multiplying  some  distance 
from  the  site  of  entrance.  Therefore  the  prophylactic 
incision  fails  of  its  purpose  and  may  do  much  harm  by 
producing  complications. 

Shall  incisions  be  made  along  the  line  of  lymphatics? 
In  those  cases  in  which  there  is  one  or  possibly  two 
red  lines,  of  lymphatic  involvement  running  up  the 
arm  the  advice  to  make  a  transverse  incision  through 
the  skin  and  subcutaneous  tissue,  so  as  to  prevent  the 
channel  from  carrying  more  toxin,  seems  logical,  and  I 
have  carried  it  out  in  a  few  cases.  I  am  convinced, 
however,  that  the  procedure  is  likely  to  do  more  harm 
than  good,  since  it  pours  out  into  the  wound  the  virulent 


350  TREATMENT  OF  LYMPHATIC  INFECTIONS 

bacteria  and  toxins  which  at  the  end  of  a  few  hours  begin 
to  be  absorbed  in  greater  amount  than  before.  The 
picture  presented  !)>'  this  procedure  is  very  characteristic. 
Within  an  hour  after  the  cut  is  made  the  part  proximal 
to  the  incision  becomes  pale,  the  red  lymphatic  disappears, 
and  the  surgeon  feels  that  his  procedure  has  been  justified 
by  the  results.  At  the  end  of  a  few  hours,  however,  it  is 
seen  that  the  portion  distal  to  the  incision  has  begun  to 
assume  a  reddish  tinge,  and  shortly  a  considerable  area 
takes  on  the  characteristic  appearance  of  an  erysipelas, 
with  an  aggravation  of  the  symptoms. 

In  other  instances  the  little  lacunae  found  in  the  course 
of  the  lymphatic  vessels  (see  p.  314)  show  small  areas  the 
size  of  a  bean  in  the  course  of  the  lymphatics,  at  which 
sites  there  is  a  local  swelling  and  edema.  These  are  most 
common  on  the  dorsum  of  the  hand.  The  thoughtless 
are  inclined  to  incise  these  under  the  impression  that 
localization  will  be  found  there  and  that  drainage  is 
indicated.  If  incision  is  made,  however,  only  a  small 
amount  of  serum  will  exude,  and  in  the  severe  cases  the 
procedure  is  generally  followed  by  a  chill  and  rise  of  fever 
within  an  hour  or  two,  sometimes  to  an  alarming  degree, 
while  the  procedure  is  detrimental  rather  than  beneficial 
to  the  ultimate  course. 

If  incision  is  made  in  these  cases  for  any  cause,  the 
possibility  of  spreading  the  infection  must  be  borne 
in  mind  and  one  should  seek  at  least  to  prevent  rapid 
absorption.  This  is  done  by  keeping  the  arm  absolutely 
at  rest  and  applying  a  Bier  constrictor  to  the  arm.  This 
should  be  left  on  for  from  twelve  to  eighteen  hours. 
These  incisions  will  be  called  for  in  those  cases  in  which 
localization  in  the  tendon  sheaths  or  in  the  subcutaneous 
tissues  has  taken  place,  as,  for  instance,  on  the  back  of  the 
forearm  or  about  the  glands.  (For  a  discussion  of  these, 
see  Chapter  XXIV.) 


DISCUSSION  OF  VARIOUS  PROCEDURES  351 

Systemic  Treatment. — Antagonistic  Drugs. — Various 
drugs  have  been  vaunted  from  time  to  time  as  of  excep- 
tional value  in  septic  conditions.  They  may  be  classified 
as  those  designed  to  destroy  bacteria  and  those  to  neutral- 
ize the  toxin.  The  value  of  any  of  them  is  questionable. 
Quinine  has  been  used  for  many  years,  and  if  it  were  of 
marked  value  sufficient  positive  evidence  should  have 
accumulated  by  this  time  to  leave  no  doubt,  and  this 
cannot  be  said  to  be  true.  The  same  may  be  said  of 
urotropin  and  the  various  silver  salts  which  have  been 
vaunted  so  highly.  Upon  none  of  these  can  the  surgeon 
depend  with  any  distinct  hope  that  they  will  be  of  value. 
The  use  of  whisky  is  in  a  different  class.  Any  value  it 
may  have  depends  upon  the  fact  that  its  elements  are  less 
stable  than  normal  cell  protoplasm,  and  consequently 
there  is  some  hope  that  the  toxin  may  unite  with  these 
rather  than  cause  destruction  of  the  living  cells.  There 
ma}^  be  some  truth  in  this.  The  trouble  is  that  to  be  of 
much  value  in  this  regard  there  should  be  a  considerable 
amount  in  the  blood,  and  the  excretion  of  any  considerable 
amount  would  be  injurious  to  the  kidneys. 

In  this  connection  it  has  been  my  habit  to  give  these 
patients  who  are  seriously  ill  fully  peptonized  food  per 
rectum  if  they  cannot  take  it  by  mouth,  so  as  to  introduce 
into  the  blood  peptones,  less  stable  than  normal  albumin 
of  the  living  cells,  with  the  hope  that  the  toxins  will  unite 
with  the  less  stable  combinations  and  thus  protect  the 
system.     This  can  do  no  harm,  and  may  do  good. 

Related  to  this  we  have  the  use  of  normal  salt  solution 
or  plain  water  introduced  into  the  system  per  rectum,  as 
well  as  large  amounts  of  water  and  fluids  by  mouth.  In 
serious  cases  the  normal  salt  may  be  given  subcutaneously, 
but  here  we  run  the  danger  of  localizing  an  infection  so 
that  I  have  abandoned  its  use  in  most  cases.  It  is  my 
belief  that  the  introduction  of  large  amounts  of  fluid  with 
the  idea  of  diluting  and  eliminating  the  toxins  is  of  great 
value. 


352  TREATMENT  OF  LYMPHATIC  IXFECTIONS 

Serum  and  Vaccine  Treatment. — We  have  not  as  yet 
develojDed  any  serum  or  vaccine  that  can  be  said  to 
be  of  definite  value  in  these  acute  cases.  The  field  is  a 
most  engaging  one,  and  many  attempts  have  been  made 
to  produce  an  antitoxin.  The  difficulties  seem  to  be 
almost  insuperable.  If  given  very  early  it  might  have 
some  effect,  since  some  of  the  sera,  such  as  that  of  Aronsen, 
have  some  bactericidal  in  addition  to  its  antitoxic  and 
opsonizing  effect.  Often  the  toxemia  is  well  advanced, 
and  such  an  immense  amount  of  antitoxin  would  be 
necessary  to  neutralize  the  toxins  that  we  cannot  hope  to 
inject  it,  and  the  opsonizing  and  bactericidal  effects  are 
insufficient.  Moreover,  it  has  been  shown  many  times 
that  the  antitoxin  prepared  for  one  type  of  streptococcus 
will  have  no  effect  upon  the  toxins  generated  by  another 
type  of  streptococci.^ 

Van  de  Velde  showed  that  the  leukocidin  produced 
by  one  Staphylococcus  pyogenes  aureus  might  be  almost 
innocuous,  while  another  might  be  most  virulent.  Denys, 
Van  de  Velde,  Neisser,  and  Wechberg  have  produced 
antileukocidin,  but  it  must  be  for  the  specific  organism. 

Therefore,  to  secure  the  best  results  a  serum  must  be 
made  from  the  germ  producing  the  disease,  and  this  is 
manifestly  impossible,  since  the  time  is  too  short.  In 
attempts  to  obviate  this  difficulty  some  have  made  their 
antistreptococcus  serum  from  a  combination  of  several 
strains  of  streptococci,  i.  e.,  the  so-called  polyvalent 
antistreptococcus  sera,  such  as  those  of  Tavel,  Moser, 
Menser,  and  others,  while  the  sera  of  Marmorek  and 
others  is  monovalent,  i.  <?.,  made  from  one  strain. 
Whether  these  sera  act  in  a  bactericidal  or  antitoxic 
manner  or  by  stimulating  cellular  activity  is  a  subject  for 
discussion,  but  at  least  the  effect  is  inadequate.  It  is 
possible  that  in  the  more  chronic  types  vaccines  may  be 

1  Meakins,  Phagocytic  Immunity  in  Streptococcus  Infection,  Jour.  Exp.  Med., 
xi,  815. 


DISCUSSION  OF  VARIOUS  PROCEDURES  :^53 

produced  that  will  aid  somewhat.  In  this  connection  a 
perusal  of  Case  XXI\^  should  he  of  interest.  In  this  case 
almost  all  of  these  methods  were  tried  without  avail. 

The  injection  and  use  of  elements  designed  to  increase 
leukocytosis  is  another  favorite  method  of  treatment. 
For  this  purpose  several  drugs  have  been  used,  as,  for 
instance,  protonuclein  and  nucleic  acid,  but  without 
definite  results.  His  has  suggested  the  injection  of  sterile 
exudate,  secured  incident  to  aseptic  injections  of  the 
pleural  cavities  of  lower  animals  with  aleuronat.  As  yet 
this  has  not  secured  a  trial. 

In  spite  of  the  lack  of  definite  results  by  any  of  these 
methods,  one  cannot  but  hope  that  the  future  holds  some 
promise  of  aid  from  these  studies.  The  surgeon  should 
always  have  in  mind  the  possibility  of  value  from  the 
sera,  watching  his  patients  closely  for  a  favorable  oppor- 
tunity; but  as  the  case  now  stands  it  is  my  personal 
opinion  that  he  is  not  in  position  to  promise  his  patients 
any  distinct  curative  action  in  the  more  acute  cases. 

Supportive  Measures. — Supportive  measures  in  the 
way  of  stimulants,  fresh  air,  good  food,  attention  to  the 
bowels,  and  proper  rest  should  not  be  neglected.  Fresh 
air  and  sunlight,  especially  in  the  more  chronic  cases, 
is  of  distinct  value.  One  patient  suffering  from  such  a 
chronic  infection,  which  defied  all  manner  of  treatment, 
was  transferred  to  an  open-air  sun  room  where  he  lived 
and  slept.  The  benefit  of  the  change  was  evident  to 
everyone.     (See  Case  XXIV.) 

Resume. 

Treatment  of  lymphatic  infection  is  based  upon  two 
principles — conservatism  and  conservation.  In  general 
we  use  local  means  tending  to  wall-off  and  overcome 
infection,  combined  with  procedures  designed  to  support 
the  system,  eliminate  the  toxin,  and  increase  its  resisting 
power. 
23 


354  TREATMENT  OF  LYMPHATIC  INFECTIONS 

Local  Procedures:  Hot,  moist  dressings  applied 
voluminously  should  be  used  until  the  infection  is  walled 
off.  Boric  acid,  potassium,  permanganate,  and  other 
solutions  may  be  used.  Both  local  and  systemic  rest 
should  be  insisted  upon.  The  Bier  treatment  is  of  some 
value  in  preventing  rapid  extension  of  the  infection. 
Incisions  should  not  be  made  unless  there  is  an  absolute 
surety  that  there  is  an  accumulation  of  pus. 

Systemic  treatment  such  as  quinine,  whisky,  urotropin, 
and  silver  salts  all  have  advocates  and  in  certain  instances 
may  be  of  value,  although  probably  in  the  majority  of 
cases  they  will  be  found  to  be  of  no  use. 

Peptonized  food  by  rectum  may  be  of  value.  Large 
amounts  of  normal  salt  or  water  is  probably  a  great  aid 
in  diluting  and  eliminating  the  toxin. 

Serum  and  vaccine  treatment  have  not  given  distinct 
aid  in  these  cases. 

Supportive  measures  in  critical  cases  are  always  a  great 
benefit. 


CHAPTER   XXIV. 

THE  TREATMENT  OF  THE  COMPLICATIONS 
OF  LYMPHANGITIS. 

TENOSYNOVITIS. 

Attention  has  been  drawn  to  the  frequency  of  teno- 
synovitis in  lymphatic  infections  beginning  in  the  distal 
phalanges  on  the  volar  surface.  In  the  chapter  dealing 
with  the  subject  of  tendon-sheath  infections  (Chapter  XI) 
a  complete  discussion  has  been  given  which  should  enable 
the  student  to  diagnosticate  the  presence  of  such  a  compli- 
cation, and  rules  have  been  laid  down  for  the  treatment 
that  has  been  most  successful  in  my  hands. 

SUBCUTANEOUS  ABSCESSES. 

Subcutaneous  abscesses  frequently  appear  upon  the 
dorsum.  As  soon  as  a  definite  redness  and  hardness  have 
appeared,  indicating  pus,  free  incisions  should  be  made. 
Simple  redness  and  edema  is  not  sufficient  to  indicate 
incision,  but  when  the  hardness  has  been  added  free 
incisions  under  the  same  precautions  as  mentioned  above 
should  be  made.  The  presence  of  extensive  subcutaneous 
destruction  of  the  connective  tissue  with  the  formation 
of  a  slough  with  streptococcus  pus  is  one  of  the  most 
serious  complications.  Incision  should  be  made  early, 
in  several  places  upon  the  dorsum,  so  as  to  give  perfect 
drainage.  At  the  risk  of  useless  repetition,  let  me  say 
again  that  I  am  speaking  of  the  indurated,  brawny,  dark 
red  dorsum,  characteristic  of  the  spreading  virulent 
phlegmon,  not  of  the  pinkish,  edematous,  pitting  dorsum. 
Neither   am    I    speaking   of    the   simple   staphylococcus 


356  TREATMENT  OF  COMPLICATIONS  OF  LYMPHANGITIS 

abscess.     The  gravity  of  this  vsevere  type  has  long  been 
recognized.^ 

PERIGLANDULAR   ABSCESSES. 

IVTighinduhir  abscesses  occur  especially  on  the  e])i- 
trochlear  and  axillary  regions.  These  are  not  so  virulent 
as  the  type  just  described,  and  a  more  conservative  course 
may  be  pursued.  Since  they  start  from  glandular  sup- 
puration, some  days  will  elapse  before  they  become 
evident.  The  surgeon  will  often  be  in  doubt  for  a  day  or 
two  as  to  whether  the  infection  may  not  be  a  simple 
glandular  hyperplasia.  The  waiting  period  is  not  without 
advantage  to  the  patient,  since  it  offers  an  opportunity 
for  the  abscess  to  become  walled  off,  and  thus  favors  the 
prevention  of  extension  when  it  is  opened. 

SUBCLAVICULAR   AND    SHOULDER  ABSCESSES. 

The  occurrence  of  such  an  abscess  will  of  course  be 
rare,  since  they  arise  in  the  course  of  the  lymphangitis 
extending  along  the  lymphatics  lying  in  the  pectero-deltoid 
groove,  having  its  origin  most  commonly  in  the  middle 

'  Bauchet  thus  describes  how  they  were  considered  and  treated  by  Velpeau: 
"An  unconfined  phlegmon  is  one  of  the  most  serious  complications  of  a  whitlow. 
It  is  heralded  by  a  series  of  serious  symptoms  here  as  in  all  other  parts,  by  a 
considerable  swelling,  and  a  characteristic  dull,  yellowish  redness. 

"The  diffuse  phlegmon  is  undoubtedly  a  serious  matter  when  it  appears  on 
the  back  of  the  hand,  but  it  is  even  more  dangerous  when  it  invades  the  forearm 
and  arm. 

"The  first  symptoms  of  this  awful  complicarion  once  recognized,  one  must 
not  hesitate  to  have  recourse  to  the  most  drastic  therapeutic  measures;  anti- 
phlogistics,  local  and  general  baths,  purgatives,  opiates,  and  the  arm  placed  in 
an  elevated  position.  If  at  the  end  of  twenty-four  or  thirty-si.\  hours  the  symp- 
toms do  not  mend,  and  if  the  disease  seems  stationary,  one  must  insist  upon  the 
compresses,  if  the  patient  has  been  able  to  stand  them,  after  generous  applica- 
tions of  ointments  of  mercury.  If  the  compresses  increase  the  pain,  one  may 
profitably  resort  to  the  application  of  a  large  volatile  vesicatory,  covering  all  the 
diseased  parts.  This  means,  so  extolled  by  M.  Velpeau,  has  and  always  will 
render  good  service. 

"However,  if  the  general  symptoms  continue  to  grow  worse,  if  the  swelling 
increases,  the  moment  to  proceed  with  the  bistoury  has  come,  and  three  or  four 
long  deep  incisions  must  be  made.  This  is  the  only  road  to  recovery  left  to  the 
patient." 


CHRONIC  INFECTIONS:  REPEAT  I'll)  INFECTIONS     357 

finger.  I(  has  Ix'cn  my  fortune  to  niccl  with  only  one 
such  case,  and  this  began  in  the  index  finger.  Dr.  J.  M. 
Neff,  has  vsccn  and  operated  upon  another  one,  in  which 
the  origin  was  in  the  middle  finger,  followed  in  three  days 
by  a  subclavicular  abscess,  which  was  opened,  and  this  in 
turn  was  followed  or  accompanied  by  a  synovitis  of 
a  knee-joint  of  a  serious  nature,  but  from  which  the 
patient  ultimately  recovered.  This  case  then  is  most 
interesting,  since  it  emphasizes  the  origin  of  these  abscesses 
and  also  serves  to  emphasize  what  I  have  previously  called 
attention  to,  and  that  is  the  seriousness  and  frequency  of 
systemic  involvement  from  lymphangitis  originating  in 
the  middle  finger. 

SYSTEMIC  COMPLICATIONS. 

These  must  be  met  as  they  arise  and  the  treatment 
based  upon  the  general  surgical  principles  governing 
septicema  and  pyemia.  The  metastatic  abscesses  should 
be  opened,  empyemas  drained,  pneumonia,  etc.,  guarded 
against  with  every  possible  precaution. 

The  question  of  amputation  of  the  arm  in  these  severe 
cases  will  be  a  constant  one,  but  no  definite  rules  can  be 
laid  down.  One  will  constantly  feel  in  the  early  cases 
that  amputation  is  too  severe  for  the  condition,  and 
when  systemic  infection  has  begun  it  will  be  considered 
that  amputation  will  be  futile,  so  that  the  indications  for 
amputation  will  be  drawn  between  narrow  lines.  In 
exceptional  cases  some  hope  may  be  offered  by  this 
procedure,  as,  for  instance,  in  a  spreading  phlegmon  or  in 
a  malignant  edema. 

CHRONIC  INFECTIONS:  REPEATED  INFECTIONS. 

It  is  an  unfortunate  fact  that  one  infection  with  the 
streptococcus  does  not  immunize  the  patient;  at  least, 
if  it  does,  it  is  only  for  a  short  time.  Not  only  are 
repeated    infections    possible,    but    one    infection    seems 


358  TREATMEXT  OF  COMPLJCATIOXS  OF  LYMPHANGITIS 

almost  to  favor  a  second  at  a  later  date.  This  is  not  true 
to  the  same  degree  with  the  staphylococcus,  by  which  a 
mild  degree  of  immunization  may  be  secured.  This  is 
demonstrated  by  the  raising  of  the  opsonic  index  as 
determined  by  the  Wright  method.  The  streptococcus 
particularly  not  only  may  not  develop  immunization,  but 
also  lacks  to  a  marked  degree  the  power  in  many  cases 
to  produce  antitoxins  in  a  degree  sufficient  to  overcome 
itself,  so  that  we  often  see  cases  of  chronic  long-continued 
infection  which  undoubtedly  had  their  origin  in  a  strepto- 
coccus infection.  No  better  example  of  this  type  of 
infection  could  be  cited  than  that  of  a  case  I  saw  with  Dr. 
Oleson,  of  Lombard,  111.  It  is  true  that  another  factor 
came  into  this  case,  namely,  that  the  infection  had 
possibly  come  from  organisms  which  had  passed  through 
a  lower  animal  which  we  know  may  change  the  \irulence 
in  many  ways.  The  case,  however,  is  worth  a  careful 
perusal,  since  it  was  so  carefully  and  conscientiously 
treated  by  Dr.  Oleson  by  every  known  scientific  method, 
and  yet  it  resisted  treatment  for  over  two  years,  the 
patient  apparently  not  having  the  slightest  ability  to 
develop  antitoxins.     He  has  now  completely  recovered. 

Dr.  Oleson  has  already  reported  the  case,  and  I  here- 
with abbreviate  his  report: 

Case  XXIV. — "On  June  15,  1906,  over  three  years  ago,  the 
patient  removed  a  wart  from  the  index  finger  of  his  right 
hand,  leaving  an  opening  in  the  subcutaneous  tissue  which 
did  not  readily  close.  While  this  condition  existed  he  received 
orders  to  care  for  some  sick  calves,  afflicted  with  a  disease 
which  caused  dyspnea,  with  considerable  sali\ation.  In 
giving  them  medicine  it  was  necessary  for  him  to  introduce 
his  right  hand  into  their  mouths,  with  the  natural  consequence 
that  it  became  covered  with  their  slobbery  saliva.  In  a  few 
days  he  sickened  and  called  in  Dr.  William  Dillon,  of  Urbana, 
who  reports  under  date  of  August  18,  1906,  substantially  as 
follows : 

*"In  regard  to  Mr.  J.'s  illness,  I  was  called  to  his  room 


CHRONIC  INFECTIONS:  REPEATED  INFECTIONS     359 

about  9  P.A[.,  June  27  (1906).  1  found  him  lying  clown,  with 
perspiration  in  largo  drops  over  his  face,  pulse  full  and  rapid, 
temperature  about  103°  F.  Pain  about  axilla.  Axillary  glands 
indurated  and  enlarged.  There  was  a  small  unhealed  place  in 
the  center  of  a  spot  on  one  of  his  right  fingers,  from  which  I 
could  press  out  a  little  serum,  but  which  had  no  soreness.  I 
ordered  fomentation  during  the  night,  with  magnesia  sulphate 
internally.  The  following  morning  there  was  less  pain,  but 
more  fever,  and  I  had  him  removed  to  a  hospital,  where  the 
treatment  was  continued.  The  glands  returned  to  their  normal 
size  so  far  as  could  be  detected,  but  fever  and  sweating  con- 
tinued. About  the  third  day  in  the  hospital  painful  tympan- 
ites developed,  also  swelling  along  the  general  direction  of  the 
pectoralis  tendon  from  a  little  below  the  arm-pit  to  near  the 
eleventh  rib.  This  was  the  first  appearance  of  localization.  I 
called  in  Dr.  Newcomb,  who  aseptically  incised  the  tissues 
do\\Ti  through  the  deep  fascia.  A  little  serum  escaped.  About 
July  22  the  second  incision  was  made  and  the  entire  cavity 
washed  out  with  bichloride  and  dressed  with  dry  dressings. 
Now  the  patient  rapidly  improved  and  the  abscess  walls 
united  so  that  when  irrigated  the  fluid  would  extend  but  a 
short  distance  in  any  direction.  The  pus  by  July  30  had 
almost  ceased.  Temperature  normal,  pulse  normal,  patient 
bright,  no  sweating.'" 

Dr.  Oleson  here  continues  : 

"I  first  saw  the-^patient  on  August  10,  1906.  On  entering 
my  ofBce  a  limitation  of  motion  in  the  right  shoulder  and  a 
marked  cervical  scoliosis  was  evident.  He  was  pale,  anemic; 
pulse,  106;  temperature,  98°  F.  At  the  anterior  margin  of 
the  right  axilla,  along  the  border  of  the  pectoralis  major, 
appeared  a  long  scar,  presenting  at  its  upper  end  a  small 
orifice  discharging  a  thin  blue-green  serum.  A  second  opening 
existed  to  the  axillary  side  of  the  scar,  about  an  inch  below 
the  first  sinus.  No  swelling,  some  redness,  tenderness  slight, 
shoulder- joint  motion  limited,  evidently  from  scar  contrac- 
tion. A-  flexible  sterilized  probe  introduced  into  the  sinus 
with  strict  asepsis  passed  under  the  clavicle  for  some  distance 
toward  the  vertebrae,  so  that  the  general  clinical  picture 
simulated  a  cervical  Pott's.  But  a  few  days'  study  satisfied 
me  that  there  was  no  vertebral  disease,  nor  could  I  find  evi- 
dence of  any  shoulder-joint  trouble. 

"He   passed   into   the   hands  of  a  neighboring   sectarian 


360  TREATMENT  OF  COMPLICATIONS  OF  LYMPHANGITIS 

practitioner,  and  after  some  weeks  of  iinimprovement  entered 
a  homeoi)athic  hospital  in  this  city.  Here  the  grachially. 
enlarging  ulcer,  which  appeared  at  the  site  of  the  sinus  and 
slowly  spread  downward  along  the  thoracic  wall  in  the  direc- 
tion of  the  original  incision,  was  curetted,  and  the  patient 
received  considerable  x-ray  treatment,  with  a  steady  failure 
of  his  vital  forces  until  the  latter  part  of  March,  1907,  some 
nine  months  after  the  original  infections,  when,  on  the  sug- 
gestion of  the  hospital  authorities,  he  was  taken  from  the 
institution  to  end  his  days  among  his  friends.  Here  I  saw 
him  on  March  28,  1907,  since  which  time  he  has  been  con- 
tinuously under  my  care.  He  presented  then  the  typical 
picture  of  advanced  chronic  sepsis.  He  was  thin,  haggard, 
with  a  marked  Hippocratic  facies,  scoliosis  more  evident, 
temperature  running  a  classical  hectic  curve  (morning  remis- 
sions to  98°  F.,  evening  readings  varying  around  102°  F.) 
The  pulse  constantly  between  120  and  130,  having  the  appear- 
ance of  impending  death.  Locally  the  margins  of  the  sinus 
had  broken  dowoi  to  form  along  the  thoracic  wall  a  deep 
ragged  ulcer  as  large  as  the  palm  of  one's  hand  with  sinuses 
radiating  upward,  forward,  and  downward,  honeycombing 
the  tissues  in  the  pectoral  region,  while  over  the  third  and 
fourth  right  costochondral  junctions  appeared  bluish-red 
depressed  areas,  evidently  marking  points  at  which  pus  was 
about  to  appear.  The  former  bluish-green  discharge  was  now 
almost  colorless,  very  profuse,  and  of  a  thin  serous  nature, 
soaking  large  gauze  dressings  daily. 

"On  April  6,  1907,  under  chloroform  anesthesia  by  Dr. 
Pickard,  with  D.  W.  F.  Scott  assisting  me,  I  removed  inflamed 
periosteum  and  perichondrium,  with  subjacent  necrotic 
tissue  at  the  points  indicated  by  the  discolored  skin,  curetting 
from  all  accessible  places  the  various  sinuses,  scraping  out 
large  quantities  of  soft,  pale,  pulpy,  friable  granulations,  with 
free  hemorrhage  easily  checked  by  pressure.  The  patient 
was  put  to  bed  in  an  exhausted  condition,  while  my  consult- 
ants cheerfully  foretold  an  early  lethal  termination. 

"On  May  6,  1907,  I  performed  a  second  similar  operation, 
attacking  new  fresh  necrotic  areas  over  the  second  and  fifth 
costochondral  junctions.  The  result  of  these  two  operations 
was  a  considerable  improvement  in  the  pulse  curve,  which 
now  rarely  went  over  no,  while  the  temperature  did  not  pass 
above  101°,  with  no  local  change  except  the  healing  of  one 


CHRONIC  INFECTIONS:  REPEATED  INFECTIONS     301 

sinus  which  luul  invaded  the  tissues  from  the  lower  niariiin  of 
the  ulcer. 

"On  July  6,  1907,  1  performed  what  was  intended  for  a 
radical  operation,  by  making  a  deep  curved  incision  from  the 
lower  border  of  the  ulcer,  anteriorly  to  the  sternum,  separating 
the  entire  pectoral  flap  of  muscles,  reflecting  them  back  over 
the  shoulder  and  exposing  this  region  for  general  curettage. 

"After  thorough  scrapings  of  all  other  lesions  the  flap  of 
muscle  was  sutured  back  into  place.  The  patient  did  not 
react  well,  it  being  several  days  before  he  ceased  vomiting, 
and  the  general  immediate  result  of  this  intervention  was  the 
actual  spread  of  the  infection,  as  it  followed  each  suture  and 
needle  puncture  into  new  regions,  reaching  around  also  into 
the  intermuscular  septa  and  subcutaneous  tissue  of  the  back, 
a  region  previously  uninvaded.  Various  abscesses  were 
opened  during  the  next  month. 

"  During  all  this  time  the  wound  had  been  dressed  by  daily 
irrigation  through  drainage  tubes  or  along  the  sinus  tracts. 
All  sorts  of  fluids  had  been  used — normal  saline,  plain  steril- 
ized water,  iodine  water,  hydrogen  peroxide,  pure  and  in 
solutions  of  varying  strengths,  bichloride  and  phenol  dilutions, 
with  no  appreciable  improvement.  On  September  2,  1907,  I 
made  a  radical  change ;  permanently  abandoning  all  forms  of 
irrigations,  and  substituting  plain,  dry,  sterile  dressing 
with  immediate  marked  improvement  in  the  general  condi- 
tion. The  temperature  fell  to  99°  and  remained  there,  while 
the  pulse  varied  between  90  and  100.  There  had  been  nervous 
digestive  disturbances,  so  that  any  unwelcome  suggestion, 
e.  g.,  the  discussion  of  an  anesthetic  or  the  odor  of  ether,  etc., 
would  cause  a  prompt  and  thorough  emesis.  Yet  he  had 
gained  10  pounds  in  bodily  weight  in  five  months,  but  with 
the  cessation  of  irrigation,  the  digestive  derangement  ceased, 
he  took  and  retained  large  amounts  of  food,  with  cod-liver 
oil,  sevetol,  etc.,  so  that  in  the  next  five  months  he  gained  26 
pounds,  with  corresponding  physical  improvement.  By  the 
middle  oi  January,  1908,  he  was  strong,  robust,  healthy 
appearing,  but  with  absolutely  no  improvement  whatever 
in  the  local  lesion,  which  remained  stationary,  discharging 
daily  large  quantities  of  seropus,  necessitating  copious  aseptic 
dressings. 

"At  about  this  time  Dr.  Emil  Beck  announced  the  result 
of  his  work  in  the  treatment  of  certain  unhealed  sinuses  by 


362  TREATMENT  OF  COMPLICATIONS  OF  LYMPHANGITIS 

the  bismuth  paste  molliod.  Injt'ctions  were  j,nven  January 
22  and  2'6,  1908,  with  no  special  result  except  that  the  patient's 
weight  fell  off  a  little.  In  order  to  give  the  paste  a  little  better 
chance,  I  decided  to  curette  the  granulations  from  the  sinuses 
again,  and  then  to  make  a  third  injection.  This  I  did  on 
February  10,  1908,  and  on  the  morning  of  February  11,  I 
found  my  patient  with  a  pulse  of  140;  temperature,  102°; 
rusty  sputum  and  consolidation  of  the  left  lower  lobe.  A 
typical  crisis  occurred  on  the  seventh  day,  with  uncompli- 
cated convalescence.  One  peculiar  phenomenon  presented 
itself  on  the  third  morning  of  the  seizure,  when  the  patient 
suddenly  expectorated  a  single  mouthful  of  pure  pus,  of  which 
the  anatomical  origin  was  never  satisfactorily  located. 

"On  February  26,  1908,  he  returned  to  his  home  having 
lost  17  pounds,  which  he  proceeded  to  regain.  At  this  time, 
through  the  courtesy  of  Prof.  Ormsby,  I  secured  from  the 
research  laboratory  of  Parke,  Davis  &  Co.,  a  supply  of  sta- 
phylococcus vaccine,  varying  doses  being  injected  on  March 
14,  and  for  a  month  afterward,  without  effect.  Thorough 
search  was  now  made  by  Prof.  Ormsby  for  evidences  of  blas- 
tomycosis, actinomycosis,  and  tuberculosis,  with  negative 
results.  Prof.  Hektoen  now  generously  placed  at  my  disposal 
his  laboratory  facilities,  and  his  assistant,  Dr.  D.  J.  Davis, 
readily  isolated  from  the  pus  a  streptococcus  which  grew 
abdundantly  in  almost  pure  cultures,  but  presented  no 
identifying  morphological  characteristics.  The  patient's 
opsonic  index  to  this  organism  was  subnormal. 

"On  April  16,  1908,  I  injected  the  dead  bodies  of  500,000,- 
000  autogeneous  cocci  obliquely  into  the  subcutaneous  tissue 
of  the  right  thigh.  In  two  days  an  induration  appeared  at 
the  site  of  injection.  Twelve  days  from  date  of  puncture 
fluctuation  was  evident  at  this  point.  On  May  6,  twenty 
days  from  the  injection,  the  skin  here  grew  purplish.  Two 
days  afterward,  on  May  8,  under  aseptic  precautions,  I 
aspirated  some  of  the  contents  of  the  swelling,  which,  on 
examination  by  Dr.  Davis,  proved  to  be  sterile,  chemical  pus. 
On  May  15,  twenty-nine  days  after  injection,  the  skin  finally 
broke  down  and  the  contents  escaped,  leaving  a  superficial 
ulcerated  area,  which  slowly  cicatrized  across  from  the 
margins,  ultimately  healing  on  July  3,  1908,  seventy-eight 
days  after  the  date  of  injection. 

"The  history  is  that  of  each  inoculation  made  obliquely. 


CHRONIC  INFECTIONS:  REPEATED  INFECTIONS     363 

leavinj^  the  vaccine  in  the  siihciitancoiis  tissue.  As  time  went 
on  I  lessened  the  close  to  250,0()0,0()(),  60,000,000,  10,000,000, 
and  each  one  caused  the  breaking  down  of  connective  tissue, 
the  formation  of  sterile  chemical  pus,  the  death  of  the  over- 
lying skin  from  starvation — an  open  ulcer — slow  healing,  so 
that  we  finally  had  an  absolute  clinical  demonstration  of  the 
method  of  local  spread  of  this  coccus,  namely,  by  the  secre- 
tion of  toxins,  which  by  their  chemical  action  on  the  connec- 
tive tissue — not  skin,  not  muscles,  but  subcutaneous  tissue, 
fasciae,  septa,  etc. — cause  this  to  gradually  die  and  melt 
away,  destroying  the  bloodvessels  which  run  in  its  meshes, 
and  so  bringing  about  the  death  of  overlying  skin  or  under- 
lying bone,  not  by  attacking  these  structures  themselves, 
but  by  cutting  off  their  nourishment. 

"To  prove  this  I  then  proceeded  to  inject  the  same  doses 
of  dead  cocci  deeply  in  the  muscles  themselves,  beginning 
with  10,000,000  and  steadily  increasing  the  quantity  until, 
on  August  29,  1908,  I  gave  him  300,000,000 — and  not  once 
was  there  the  least  reaction,  local  or  general,  to  a  single  intra- 
muscular injection,  while  every  one  of  the  oblique  subcutane- 
ous injections  of  the  same  cultures,  with  identical  aseptic 
precautions,  produced  local  necrosis. 

"During  this  period,  while  we  were  endeavoring  to  do 
something  to  help  the  patient  by  means  of  specific  vaccine, 
his  general  condition  failed  slightly.  He  lost  about  8  pounds 
in  weight,  and  there  was  a  slow  spreading  by  undermining 
the  skin  around  the  affected  area,  so  that  at  the  end  of  this 
time,  when  this  method  was  abandoned,  the  area  involved 
reached  its  maximum,  covering  the  right  side  of  the  body  from 
the  sternum  into  the  middle  of  the  right  half  of  the  back  and 
extending  from  a  point  above  the  clavicle  down  beyond  the 
costal  margin — -a  stretch  of  29  cm.  in  each  diameter.  I  now 
decided  to  expose  the  affected  region  thoroughly,  and  on 
September  15,  1908,  I  curetted  again  all  sinuses  and  com- 
pletely excised  all  undermined  skin.  At  last  this  was  fol- 
lowed by  actual  healing. 

"For  some  time  I  had  been  anxious  to  give  my  patient  the 
benefit  of  sunshine  in  direct  application  to  the  wound  surfaces, 
but  no  practicable  method  presented  itself  to  me  on  account 
of  the  large  area  to  be  covered  and  the  very  free  discharge. 
Fortunately,  on  November  28,  1908,  Dr.  Allen  B.  Kanavel 
saw  him  and  suggested  a  homemade  wire  cage.     This  crude 


364  TREATMENT  OF  COMPLICATIONS  OF  LYMPHANGITIS 

appliance  was  applied  on  I)(((inlur  ,^.  and  prosed  to  \)v  ihe 
one  missinj^  link  in  the  chain  to  drag  the;  patient  hack  to 
health.  The  wire  cage  was  cnNi'loped  with  sterile  gauze,  and 
so  enfolded  and  protected,  my  patient  has  spent  the  last 
ten  months  basking  in  the  sunlight,  with  slow  hut  steady 
healing  of  the  local  lesions  in  all  spots  the  sun's  direct  rays 
could  reach.  The  range  of  pulse  is  in  the  sixties,  the  tempera- 
ture normal,  and  the  general  condition  most  excellent." 

The  history  of  this  patient  serves  to  emphasize  that 
such  cases  the  general  hygienic  rules  are  of  more  value 
than  any  special  procedures.  This  would  include  out- 
door life  and  nourishing  food,  combined  with  the  least 
possible  local  treatment  of  the  infected  areas.  The 
futility  of  vaccine  treatment  was  also  emphasized. 

Resume. 

Tenosynovitis  should  be  treated  here,  when  it  appears, 
as  elsewhere.  Description  of  this  technique  will  be 
found  in  the  chapters  dealing  with  that  subject. 

Subcutaneous  abscesses  which  appear  upon  the  dorsum 
should  be  opened  freely  but  simple  redness  and  edema  do 
not  indicate  pus  and  an  incision  should  not  be  made. 

In  phlegmonous  lymphangitis  extensive  incision  should 
be  made  upon  the  dorsum. 

Periglandular  abscesses  should  be  opened  when  they 
appear.  One  should  be  conservative  and  not  make 
incision  too  early. 

Systemic  infection  should  be  treated  upon  the  same 
general  principles  as  septicemia  and  pyemia. 

Chronic  infections  and  repeated  infections  are  probably 
better  treated  by  general  supportive  treatment,  such  as 
outdoor  life,  nourishing  foods,  etc.,  although  in  certain 
cases  vaccines  have  been  found  to  be  of  value. 


(  HAPTER   XXV. 
HAND  INFECTIONS  AMONG  EMPLOYES. 

A  CONSIDERATION  OF  METHODS  OF  PREVENTION  AND  AN 
ECONOMIC  PLAN  OF  TREATMENT. 

The  author  is  indebted  to  Dr.  Harry  E.  Mock  for 
much  of  the  data  found  in  the  following  chapter.  An 
extensive  experience  gathered  through  several  years  as 
surgeon  to  one  of  our  largest  industries  supplemented  by 
careful  records  and  especial  study  upon  this  subject  has 
fitted  him  to  speak  with  authority. 

The  "safety  first"  movement  which  has  swept  over  the 
country  during  the  last  few  years  has  brought  most 
forcibly  to  the  employer,  the  employe,  and  above  all  to 
the  company  surgeon  the  importance  of  preventing  acci- 
dents. In  fact,  the  pioneer  efforts  along  these  lines  of  a 
few  company  surgeons  really  mark  the  beginning  of  this 
great  movement. 

Safety  engineers  connected  with  many  of  the  large 
industrial  concerns  have  perfected  guards  for  machinery 
and  various  other  forms  of  apparatus,  which  have  greatly 
reduced  the  number  of  serious  accidents  among  employes. 
But  the  most  troublesome  question  among  employers  is: 
How  to  prevent  the  minor  accidents.  These  at  first  seem  so 
trivial,  but  too  often  they  develop  complications — chiefly 
infection-^and  thus  cause  considerable  loss  of  time  and 
frequently  deformities  or  other  forms  of  permanent  dis- 
ability. Likewise,  the  surgeon  must  carry  this  "safety 
first"  movement  into  the  active  treatment  of  all  injuries, 
choosing  that  line  of  treatment  which  will  give  the  most 
rapid  recovery,  and  which  will  prevent  as  far  as  possible 
permanent  disability  or  loss  of  life. 


366  HAND  INFECTIONS  AMONG  EMPLOYES 

In  hand  infections  following  injuries,  we  have  one  of  the 
best  examples  of  the  company  surgeon  as  the  safety  first 
expert.  Minor  injuries  such  as  scratches,  abrasions,  pin 
pricks,  nail  and  splinter  wounds,  etc.,  have  proved  most 
difficult  for  industrial  concerns  to  prevent,  and  it  devolves 
on  the  company  surgeon  to  prevent  infections  from  de- 
veloping in  these  slight  wounds;  or  if  infection  has 
already  developed  to  treat  it  so  thoroughly  and  actively 
as  to  prevent  prolonged  loss  of  time  from  work,  loss  of 
function  in  a  member,  and  above  all,  death. 

PREVALENCE  OF  HAND  INFECTIONS. 

The  part  played  by  hand  infections  in  the  economy  of 
the  industrial  world  is  shown  by  the  following  statistics 
and  statements  from  various  industries  and  accident 
insurance  companies: 

1.  From  4971  accidents,  654,  or  11  per  cent,,  became 
infected. 

Total  disability  from  these  accidents  was  13,000  days, 
and  20  per  cent,  of  this  was  due  to  the  infections. 

2.  From  one  of  the  stock  yard  plants: 

75  per  cent,  of  disability  from  hand  injuries  is  the  result 
of  infections. 

25  per  cent,  of  disability  from  hand  injuries  is  due  to 
other  causes,  such  as  broken  bones,  etc. 

90  per  cent,  of  these  hand  infections  report  late,  after 
the  infection  has  developed. 

75  per  cent,  of  these  hand  deformities  are  the  result 
of  infections. 

A  number  of  fingers  are  amputated  each  year  because 
of  these. 

3.  Figures  obtained  from  the  claim  departments  of  five 
of  our  largest  accident  insurance  companies: 

(a)  15  per  cent,  of  the  total  disability  is  due  to  hand 
injuries.  In  20  per  cent,  of  these  hand  injuries  the 
disability  is  due  to  infections. 


PREVALENCE  OF  HAND  INFECTIONS  367 

{b)  7  to  9  per  cent,  of  the  total  disability  from  all 
accidents  is  due  to  hand  infections. 

(c)  From  i,ooo  consecutive  cases,  5.7  per  cent,  of  the 
total  disability  was  due  to  hand  infections. 

{d)  From  10  to  20  per  cent,  of  the  total  disability  is 
due  to  hand  infections — it  depends  on  the  type  of  work 
done  by  insured.  When  engaged  in  heavy  work  where 
the  injuries  are  usually  serious  the  infections  are  less,  but 
if  engaged  in  light  work,  where  minor  accidents  are  the 
the  rule,  the  infections  are  greatly  increased. 

{e)  Of  all  hand  accidents,  it  is  estimated  that  65  per 
cent,  requiring  disability  are  the  result  of  minor  injuries 
which  have  become  infected;  35  per  cent,  requiring  dis- 
ability are  due  to  other  injuries,  as  broken  fingers,  lacera- 
tions, crushing  injuries,  etc. 

In  talking  with  a  number  of  company  surgeons  and 
managers  of  claim  departments,  I  find  that  no  definite 
statistics  are  avilable  on  this  subject.  They  all  agree, 
however,  that 

1.  Hand  infections  cause  a  high  percentage  of  their 
disability. 

2.  Over  50  per  cent,  of  their  hand  deformities  are  the 
result  of  infected  injuries. 

3.  A  great  many  amputations  result  from  neglected 
infected  fingers. 

4.  Hand  infections  are  usually  the  result  of  minor 
injuries,  such  as  pin  pricks,  nail  wounds,  splinters, 
scratches,  small  cuts,  cracked  hands,  blisters  contusions, 
abrasions,  etc.  Such  minor  cases  as  a  rule  do  not  report 
to  the  doctor  until  the  infection  has  developed. 

5.  Severe  hand  injuries  such  as  extensive  lacerations, 
severe  crushing  injuries,  etc.,  are  seldom  infected.  The 
nature  of  these  injuries  is  such  that  the  patients  are  forced 
to  consult  a  doctor  at  once.  In  the  packing  room  of  one 
large  industry,  the  infected  hands  due  to  nail  and  splinter 
wounds,  abrasions  from  the  boxes  and  baskets,  contusions 


368  HAND  INFECTIONS  AMONG  EMPLOYES 

and  small  cuts  are  70  per  cent,  more  than  in  the  machine 
shops  of  this  same  concern  where  the  injuries  to  the 
hands  are  usually  quite  severe. 

6.  The  industrial  commission  of  one  State  gives  figures 
showing  that  one  out  of  every  15  injuries  becomes  infected, 
and  these  are  chiefly  minor  injuries. 

7.  That  early  treatment  of  all  accidents,  no  matter 
how  slight,  would  reduce  infections  to  a  marked  degree. 

ETIOLOGY  OF  INFECTIONS  AMONG  EMPLOYES. 

In  studying  the  causes  of  these  infections  from  several 
thousand  cases  coming  under  his  care  Mock  has  brought 
out  a  number  of  very  important  points,  a  knowledge  of 
which  has  been  a  great  aid  in  developing  the  work  of 
prevention  of  these  infections. 

From  a  bacteriological  standpoint,  the  staphylococcus, 
both  aureus  and  albus,  has  caused  a  majority  of  the 
infections.  Some  of  the  most  serious  cases,  causing  a 
prolonged  disability,  have  been  due  to  a  chronic  staphylo- 
coccus infection.  The  streptococcus  comes  next  in  fre- 
quency, and  usually  causes  a  very  rapid,  severe  inflamma- 
tion with  marked  tendency  to  spread  to  various  spaces 
in  the  hand  and  to  the  forearm.  This  organism  has  been 
found  in  practically  all  the  cases  of  lymphangitis. 

In  the  winter  months,  when  tonsillitis  is  most  prevalent, 
hand  infections  have  been  found  to  be  correspondingly 
more  frequent.  A  number  of  these  hand  infections  have 
been  due  to  the  action  of  a  hemolytic  streptococcus,  and 
have  either  been  associated  with  or  followed  an  attack  of 
tonsillitis.  A  careful  bacteriological  study  of  a  series  of 
these  cases  resulted  in  finding  the  same  hemolytic  strepto- 
coccus as  the  cause  of  both  the  tonsillitis  and  the  hand 
infection.  The  following  table  shows  this  relationship. 
Note  the  increase  in  hand  infections  with  the  increase  in 
tonsillitis. 


ETIOLOGY  OF  INFECTIONS  AMONG  EMPLOYES      369 
From  a  workinii  force  of  it,ooo  employes: 

January  and  February,  1913:    Total  number  of  cases  of  tonsillitis     327 
January  and  February,   1913:     Total  number  of  cases  of  hand 

infections 83 

Total  number  of  days  of  disability  from  hand  infections  63 

Number  of  hand  infections  having  tonsillitis  at  the  time  or 
just  before  infection  developed     .  15,  or  18  per  cent. 

In  19 14  we  had  in  Chicago  a  serious  epidemic  of  ton- 
silHtis,  usually  of  the  streptococcic  type. 
From  the  same  working  force: 

January  and  February,  1914:    Total  number  of  cases  of  tonsillitis     603 
January  and  February,  1914:  Total  number  of  cas^s  of  hand  infec- 
tions      117 

Total  number  of  days  of  disability  from  hand  infections   .      .      208 
Number  of  hand  infections  having  tonsillitis  at  time  or  just 
before  infection  developed 32,  or  27.9  per  cent. 

In  19  of  these  cases,  the  hand  infection  was  very 
severe,  with  lymphangitis  and  extensive  tenosynovitis.  • 
Twelve  of  these  were  due  to  a  hemolytic  streptococcus, 
and  the  same  organism  was  found  in  the  patients'  tonsils. 
Twelve  others  had  a  marked  lymphangitis,  and  while 
the  organism  was  not  ascertained,  yet  these  were  un- 
doubtedly streptococcus  infections  and  closely  related  to 
the  tonsillitis. 

The  Bacillus  pyocyaneus  has  been  found  in  many 
of  these  infected  hands.  It  usually  causes  a  more  or 
less  chronic  infection  with  a  tendency  to  spread  under 
the  skin  as  a  subepithelial  infection.  Other  organisms 
have  been  found  in  isolated  cases  among  the  infected 
hands  of  workers,  as  follows:  Bacillus  pseudodiphtheria, 
Bacillus  Goli  communis.  Bacillus  tetani,  and  one  case  of 
sporotrichosis. 

The  chief  contributing  factors  to  hand  infections  noted 
among  industrial  employes  are: 

I.  Failure  of  employe  to  report  to  doctor  for  suitable 
dressing  immediately  after  the  injury  is  received:  minor 
accidents  are  more  frequently  infected. 
24  ,  - 


370  HAND  INFECTIONS  AMONG  EMPLOYES 

2.  Too  much  dependence  on  a  ftrst-eiid  outfit  and  an 
emergency  man.  Many  cases  are  treated  by  the  first- 
aid  emergency  man  which  should  be  sent  to  a  surgeon 
at  once,  instead  of  waiting  until  the  infection  has  de- 
veloped. 

3.  The  fellow  employe  as  a  first  aid.  Too  often  a 
kindly  fellow  employe  will  remove  a  splinter  with  a  dirty 
knife  or  pin,  or  will  apply  some  homely  remedy  to  a  cut 
or  nail  wound,  whereas  if  these  services  were  not  offered, 
the  injured  worker  would  have  consulted  the  surgeon  at 
once.  Remedies  commonly  used  by  such  employes  are 
tobacco  that  has  been  chewed,  or  washing  out  the  wound 
with  hydrogen  peroxide  or  tap  water  and  then  applying" 
a  rag  or  waste  which  is  far  from  sterile. 

4.  The  anemic,  undernourished,  or  run-down  individual, 
or  the  person  who  works  in  an  ill-ventilated  space  and 
takes  very  little  outdoor  exercise  is  far  more  prone  to 
infections.  Faulty  home  conditions,  such  as  overcrowd- 
ing, sleeping  in  bedrooms  with  poor  ventilation,  have 
frequently  been  found  on  visiting  these  infected  employes. 

5.  Packers,  porters,  restaurant  workers,  such  as  waiters 
and  dish-washers,  garment  workers,  inside  truckers, 
filing  girls,  stenographers,  clerks  and  of^ce  workers  are 
more  prone  to  hand  infections  than  machinists  and  out- 
side workers  such  as  carpenters,  masons,  gardeners,  team- 
sters, railroaders,  etc. 

The  incubation  period  for  the  various  types  of  hand 
infections  was  worked  out  In  a  large  series  of  cases  which 
did  not  report  to  the  company,  hospital  until  after  the 
infection  was  fully  developed. 

Number  of  days 
Type  of  infection.  after  injury. 

Paronychia 1  to    8 

Subepithelial  abscesses 1  to  4 

Felons 3  to  10 

Carbuncular 2  to  4 

Lymphangitis 1  to  2 

Tenosynovitis 3  to  6 

Thenar  and  palmar  space 3  to  6 

Axillary  abscess   . 3  to  7 


PREVEATIOy  OF  HAND  INFECTIONS  371 

PREVENTION   OF   HAND    INFECTIONS. 

As  stated  above,  a  careful  study  of  the  etiology  of  every 
infection  will  show  that  the  majority  are  due  to  prevent- 
able minor  accidents,  and  by  a  removal  of  these  causes  a 
great  reduction  in  infections  will  ensue.  These  causes 
can  be  classified  as  those  found  in  the  working  place  and 
those  found  in  the  employe. 

Education  of  both  the  employer  and  the  employe  is 
necessary  to  remove  the  causes  found  in  the  working  place. 
As  an  example:  The  lining  of  bins  which  had  become 
loosened  was  the  frequent  cause  of  injuries  which  became 
infected.  In  every  case,  a  notice  was  sent  to  the  manager, 
pointing  out  the  preventable  nature  of  this  accident,  and 
in  one  year  the  injuries  from  this  source  were  reduced  from 
75  to  10.  The  same  procedure  was  then  followed  in  the 
case  of  broken  baskets,  exposed  ends  of  wire,  nails  on  the 
floor,  pins  in  packages,  etc.,  all  resulting  in  a  decrease  in 
minor  accidents  and  therefore  in  infections.  The 
employes  were  carefully  instructed  concerning  the  dangers 
of  these  minor  injuries,  and  were  urged  to  remove  any 
causes  for  such  injuries  which  they  found  during  the 
course  of  their  work. 

The  removal  of  causes  for  infections  found  in  the 
employe  is  a  part  of  a  vast  field  of  preventive  medicine 
and  preventive  surgery  among  industrial  workers.  Thus, 
the  discovery  of  the  diseased  employe  by  a  periodical 
medical  examination  of  all  employes  is  a  valuable  adjunct 
to  any  system  of  prevention.  By  proper  advice  many  of 
these  diseased  conditions  can  be  overcome;  a  change  of 
work  may  be  indicated  in  other  cases,  and  the  regulation 
of  the  employe's  mode  of  living,  both  at  work  and  at 
home,  and  as  regards  outdoor  exercise,  will  correct  a  great 
many  of  the  anemic,  undernourished  and  run-down  condi- 
tions. In  girls  we  frequently  see  recurring  infections  in  the 
same  individuals.     A  study  of  these  cases  will  reveal  a 


372  HAND  INFECTIONS  AMONG  EMPLOYES 

marked  anemia,  the  correction  of  which  overcomes  their 
tendency  to  infections.  The  relationship  of  tonsilHtis 
to  infections  has  already  been  mentioned.  The  removal 
of  the  tonsils  when  diseased,  therefore,  would  not  only 
stop  the  sick  disability  and  the  spread  of  the  disease 
throughout  a  department  as  an  epidemic,  but  would  be  a 
great  preventive  measure  against  infections. 

Prohibiting  employes  from  removing  splinters  or  in 
other  ways  from  promiscuously  rendering  first  aid  to 
fellow  employes  is  another  great  means  for  prevention. 

A  further  and  very  important  factor  in  the  prevention 
of  infections  is  a  suitable  emergency  office  where  the  most 
aseptic  surgical  treatment  can  be  rendered. 

The  immediate  treatment  of  all  minor  injuries  is  the 
surest  means  of  preventing  an  infection  from  developing. 
Naturally,  the  safest  agent  to  render  this  treatment  is 
the  trained  surgeon.  A  well-trained  nurse  is  the  next 
best  substitute  for  the  surgeon.  In  the  absence  of  both 
a  doctor  and  a  nurse,  a  carefully  instructed  first-aid  man, 
chosen  from  among  the  employes  and  furnished  with  a 
proper  first-aid  kit,  may  render  this  immediate  treatment 
to  the  injured  employe.  With  very  few  exceptions,  it  is 
always  safer  to  send  these  minor  cases  to  a  surgeon  as  soon 
as  possible,  even  though  a  nurse  or  first-aid  man  has  given 
them  immediate  care. 

Tincture  of  iodine  is  the  greatest  protection  against 
infection  that  can  be  used.  Every  industry  should 
supply  each  department  with  a  bottle  of  tincture  of  iodine 
and  another  bottle  containing  applicators,  and  should 
instruct  each  employe  to  paint  every  wound,  no  matter 
how  slight,  with  the  tincture  of  iodine  at  once,  even  before 
reporting  to  the  doctor.  The  importance  of  its  use  should 
be  pointed  out  to  the  department  foremen  again  and 
again,  in  order  that  they  may  instruct  each  new  employe 
as  to  its  value.  In  1909,  impressed  by  the  great  number  of 
hand  infections  reporting  to  the  doctor's  office  in  a  large 


PREVENTIOX  OF  IIAXD  IXFECTIONS  373 

industry,  Mock  installed  this  use  of  iodine  as  a  preventive 
measure.  Immediately-,  there  was  a  reduction  of  38  per 
cent,  in  the  number  of  infections.  Practically  all  of  the 
infected  cases  failed  to  use  iodine  at  once.  The  following 
figures  taken  from  a  report  show  the  importance  both  of 
using  iodine  and  of  reporting  to  the  doctor  at  once  for 
dressing: 

From  3000  accidents,  44  per  cent,  reported  at  once,  and 
41  per  cent,  used  iodine  at  once;  43  per  cent,  reported  late 
and  failed  to  use  iodine;  the  remainder  were  cases  where 
its  use  was  not  indicated.  From  the  above  number  there 
were  654  infections;  12  of  these  used  iodine  and  reported 
at  once;  24  failed  to  use  iodine,  but  reported  at  once 
618  reported  from  one  day  to  one  month  after  receiving 
the  injury,  with  the  part  infected;  of  this  number,  40  per 
cent,  used  iodine  somewhat  later,  while  60  per  cent,  failed 
to  use  it  at  all. 

The  35  infections  that  used  iodine  or  reported  imme- 
diately were  all  very  slight  and  did  not  require  opening, 
while  440  of  the  group  who  failed  to  use  it  or  reported  late 
required  incisions,  thus  necessitating  19 12  days  of  dis- 
ability and  further  decreased  efficiency  by  working  with 
a  finger  or  hand  bandaged  for  several  days.  A  large 
percentage  of  these  cases  occurred  among  new  employes. 

The  importance  of  early  reporting  to  the  doctor  for  a 
dressing  is  demonstrated  not  only  by  the  above  figures, 
but  by  the  fact  that  major  injuries,  which  force  the 
employe  to  report  at  once,  seldom  becomfe  infected. 

The  use  of  hydrogen  peroxide,  bichloride  wash,  or  soap 
and  water  on  a  fresh  wound  is  never  indicated.  These 
methods  tend  to  scatter  the  dirt  and  infection  throughout 
the  wound.  Hydrogen  peroxide  especially  by  its  foaming, 
expansive  power,  carries  dirt  deeper  into  the  wound  with- 
out killing  the  germs  of  infection.  Even  in  the  use  of 
iodine,  the  effort  is  not  so  much  to  cleanse  the  wound, 
as  to  inhibit  the  growth  of  any  germs  that  might  have  been 
introduced. 


374  II  AX  I)  IXFKCTIOXS  AMOXG   I'M  PLOY  ES 

The  following  tabic  taken  from  Mock's  experience 
shows  the  percentage  of  all  infections  as  compared  with 
the  total  number  of  accidents,  for  three  years,  demon- 
strating the  value  of  these  preventive  measures. 

Years.  Xumber  of  accidents.      Number  of  infections. 

1912 2693  772  or  28.6  per  cent. 

1913 4383  329  or    7.5  per  cent. 

1914 4971  654  or  11  0  per  cent. 

The  fact  that  the  total  number  of  infections  decreased 
so  markedly  in  the  last  two  years,  notwithstanding  a  40 
per  cent,  increase  in  the  number  of  accident  cases  report- 
ing to  the  doctor's  of^ce  was  due  chiefly'  to  the  enforce- 
ment of  the  rules  that  every  accident  case  must  report  at 
once  to  the  doctor,  and,  when  indicated,  must  use  iodine 
at  once. 

ACTIVE  TREATMENT  OF  HAND  INFECTIONS  AMONG  EMPLOYES. 

The  active  treatment  of  hand  infections  is  exhaustively 
dealt  with  in  this  book.  General  principles  of  treatment 
which  will  give  the  best  economic  results  have  been  so 
thoroughly  developed  among  certain  industries  that  a 
resume  of  these  methods  is  fully  indicated  here. 

In  an  article  entitled  "Economic  Treatment  of  Hand 
Infections,"!  Mock  sets  forth  what  he  considers  the  best 
general  principles  governing  the  treatment  of  this  condi- 
tion, based  on  the  study  of  1600  cases  of  hand  infections 
occurring  among  employes.  (Through  the  courtesy  of 
Surgery,  Gynecology  and  Obstetrics,  we  quote  parts  of  the 
above-mentioned  article  and  present  the  pictures  illus- 
trating it.) 

When  an  infection  has  once  developed,  the  best  medical 
treatment  is  at  times  the  most  expensive,  but  in  the  long 
run  it  is  the  most  economical.  Too  often,  a  doctor  hopes 
to  save  his  patient  loss  of  time,  or,  if  he  is  a  company 
surgeon,   he  hopes  to  treat  the  case  and  still  keep  the 

^  Surgery,  Gynecology  and  Obstetrics,  1915,  xxi,  481. 


ACTIVE  TREATMENT  OF  HAND  INFECTIONS 


wn 


patient  at  work:  tlius  the  surt>eon  a(lo})ts  what  at  lirst 
seems  the  most  economic  Hne  of  treatment,  but  by  so 
doing   frequently    temporizes    with    the    infection.     The 


Fig.  125. — Lymphangitis  of  the  arm  from  an  infected  abrasion  on  back  of 
hand.  Thirty-si.x  hours  in  the  hospital  with  continuous  hot  dressings  relieved 
this  condition  without  surgical  interference. 


Fig.  126. — Thenar  space  abscess  from  a  neglected  knife  wound  of  the  thumb. 
Through-and-through  drainage  under  a  general  anesthetic  and  hospital  treatment 
for  three  days  gave  prompt  recovery. 

death-rate  from  hand  infections  among  the  medical 
profession  is  notoriously  high.  I  believe  this  is  due  not  so 
much  to  the  peculiar  nature  of  the  doctor's  w  ork,  wherein 
he  is  brought, into  close  contact  with  diseased  conditions, 


376 


HAND  INFECTIONS  AMONG  EM  PLOY  RS 


as  to  the  fact  that  mOvSt  doctors  temporize  with  an  infec- 
tion which  they  have  contracted,  rather  than  adopt 
active  treatment  at  once. 


Fig.  127. — Tenosynovitis  of  middle  finger,  with  middle  palmar  abscess — result 
of  cutting  finger  on  steel  tag.  Was  given  ambulatory  treatment,  with  an  effort 
to  drain  abscess  through  small  incision  on  flexor  surface  of  finger.  Proper 
drainage  ijf  the  syno\  ial  sheath  of  the  middle  finger  would  have  prevented  this 
condition. 


Fig.  128. — Deformity  of  hand — result  of  generalized  cellulitis  of  forearm  and 
involvement  of  radial  and  ulnar  burste.  Initial  injury:  slight  contusion  at  base 
of  palm.  Early  hospital  treatment  and  proper  diagnosis  of  the  location  of  pus 
would  have  prevented  this  deformity. 


ACTIVE  TREATMENT  OF  HAND  INFECTIONS       377 

From  a  careful  study  of  1600  cases  of  finii^er  and  hand 
infections  and  their  comi)hcations,  during  the  hist  three 
years,  I  am  convinced  that  a  radical  form  of  treatment 
of  all  hand  infections  is  the  most  economic  plan  that  can 
be  adopted. 

The  initial  cost  of  such  treatment  will  exceed  a  tempor- 
izing efifort,  such  as  opening  an  infection  in  the  offtce  and 
allowing  the  patient  to  go  about  his.  duties,  but  the 
length  of  treatment  and  the  complications  developing 
from  the  latter  method  will  far  exceed  that  which  follows 
the  treatment  of  all  infections  as  serious  from  their  incep- 
tion. In  dealing  with  this  subject  from  an  economic 
viewpoint,  it  is  not  the  actual  cost  of  medical  services 
which  is  referred  to,  but  the  actual  economy  to  the 
patient  and  to  the  concern  for  which  he  works.  The  most 
perfect  line  of  treatment  must  give: 

1.  The  shortest  disability,  with  a  minimum  amount  of 
suffering,  and  the  fewest  hardships  to  those  dependent  on 
the  patient. 

2.  It  must  prevent  permanent  deformities,  such  as  loss 
of  function,  or  loss  of  fingers. 

3.  It  must  reduce  the  death-rate  to  a  minimum. 
These  1600  cases  of  hand  infections  were  chiefly  the 

result  of  minor  accidents  such  as  the  following,  named  in 
their  order  of  frequency:  Pin  pricks,  splinters,  abrasions 
from  baskets,  boxes,  bins,  etc.;  lacerations  from  knives, 
scissors,  and  other  sharp  utensils;  bruises  and  contusions, 
nail  wounds,  scratches  from  tin  and  wire.  The  greater 
number  of  these  infections  were  very  slight  causing  no 
loss  of  time  from  work,  and  requiring  from  3  to  10  dress- 
ings. Nevertheless,  there  was  a  certain  disability  con- 
nected with  them,  as  an  employe  with  a  bandaged  finger 
or  hand  has  less  working  capacity  than  an  unhampered 
employe.  Therefore,  reduction  in  the  total  number  of 
infections  means  a  marked  saving  in  this  form  of  dis- 
ability. It  has  been  further  reduced  by  careful  attention 
to    the   simplest,   yet   adequate,   dressing  which  can  be 


37.S  riAXD  IXPECTIONS  AMOXC.   I'M  PLOY  ES 

applied.  A  certain  luiniher  of  the  ahoxe  infections  be- 
came serious,  requiring  considerable  treatment  either  at 
home  or  at  the  hospital,  and  caused  an  actual  loss  of  time 
from  work.  Thus,  the  1600  cases  may  be  classified  as 
follows : 

(a)  Mild,  or  causing  no  loss  of  time,  1189,  or  74  per 
cent. 

{b)  Serious,  or  causing  loss  of  time,  411,  or  26  })cr  cent. 

In  order  to  arrive  at  the  best  and  most  economic 
treatment  of  these  hand  infections,  it  is  necessary  for 
us  to  study  the  411  cases  mentioned  above  which  were 
serious  enough  to  require  actual  disability. 

One  of  two  plans  of  treatment  was  adopted  in  every 
case  of  hand  infection;  namely,  ambulatory  treatment, 
or  hospital  treatment.  The  ambulatory  care  consisted 
in  opening  the  infected  part  at  the  doctor's  ofifice  and 
allowing  the  patient  to  go  home,  reporting  to  the  ofifice 
for  subsequent  dressings.  Frequently  a  local  anesthetic 
was  used  in  operating  on  these  infections,  but  a  general 
anesthetic  was  never  administered  in  the  doctor's  ofifice. 
When  necessary,  instructions  were  given  to  the  patient 
as  to  the  use  of  hot  dressings  at  home,  and  a  nurse  would 
call  to  see  that  these  instructions  were  carried  out. 
Naturally,  these  infections  were  not  so  serious  as  those 
given  hospital  treatment,  but  in  spite  of  this  fact  their 
average  disability  was  greater.  The  absolute  rest  ob- 
tained by  hospital  treatment  would  cause  more  rapid 
recovery  of  these  cases,  but  the  idea  of  going  to  a  hospital 
for  a  small,  minor  infection  does  not  appeal  to  most 
patients. 

When  a  hand  infection  showed  signs  of  becoming 
serious,  or  threatened  complications  were  apparent, 
we  insisted  on  hospital  treatment.  Here  the  infection 
could  be  opened  under  a  general  anesthetic  of  nitrous 
oxide  gas,  and  the  patient  kept  absolutely  quiet  in  bed, 
with  continuous  hot,  moist  dressings  applied  until  the 
acuteness  of  the  condition  had  subsided.     Likewise,  many 


ACTIVE  TRKATMKM'  OF  HAM)  IXFECTIOXS       :579 

cases  of  threatened  serious  infection  could  l)e  aborted  and 
the  necessit>-  of  ()i)ening  these  overcome  by  sencHng  the 
patient  to  the  liospital,  giving  him  absolute  rest  in  bed, 
preventing  the  movement  of  the  infected  part,  and  apply- 
ing continuous  hot  packs  for  twenty-four  to  forty-eight 
hours. 

The  use  of  a  general  gas  anesthetic  is  one  of  the  most 
valuable  features  of  this  hopsital  treatment  when  it  is 
necessary  to  operate  on  these  hands.  The  work  of  the 
operator  is  much  more  thorough,  and  incisions  into  the 
infected  part  are  larger  and  better  drainage  is  established. 
Wide-open,  radical  treatment  of  these  infections  means  a 
much  more  rapid  reco\'ery;  therefore  the  advantage  of 
this  procedure.  The  history  of  the  treatment  of  hand 
infections  is  one  of  following  the  pus  by  making  addi- 
tional incisions.  Frequently  an  infected  hand  is  operated 
upon  two,  three,  or  even  more  times;  whereas  if  sufficient 
drainage  is  established  at  the  first  incision,  subsequent 
openings  are  not  necessary.  Ninety-five  per  cent,  of  the 
infected  hands  requiring  two  or  more  operations  occur 
in  those  cases  given  office  treatment. 

Besides  reducing  disability,  a  number  of  these  serious 
hand  infections  would  have  resulted  in  permanent 
deformities  if  this  radical  form  of  treatment  had  not  been 
adopted  earl}'.  The  accompanying  table  demonstrates 
the  great  advantages  of  hospital  treatment  for  hand 
infections  as  compared  to  ambulator}-  treatment: 

Ambulatory  Versus  Hospital  Treatment  of  Serious  Hand  Infections. 

Treated  at  doctor's  Treated  at 

office  and  at  home.  hospital. 

Total  aumber         ......         253  146 

Opened .   •  .         210  78 

Not  opened 43  or  17%  68  or  46.5% 

Total  loss  of  time  from  work       .      .       2790  days  1088  days 
Average  loss  of  time,  per  case           .      11.02  days  7.4  days 
Permanent  disability,  as  loss  of  func- 
tion or  member        .....            0  2^ 
Deaths 0  0 

^  25  per  cent,  loss  ot  function  by  stit)'  middle  finger.     10  per  cent,  loss  of 
function  bv  stiff  thumb. 


380  HAND  INFECTIONS  AMONG  EMPLOYES 

From  a  study  of  the  above  facts,  I  am  positive  that 
dangerous  infections  can  be  prevented  and  disability  reduced 
by  the  early  adoption  of  hospital  treatment.  The  reasons 
therefore  are: 

1.  The  patient  can  be  kept  absolutely  quiet  and  under 
better  control  than  at  home.  This  is  very  essential,  as 
most  of  these  infections  are  accompanied  by  a  low-grade 
fever. 

2.  Continuous  hot  dressings  can  be  better  applied  by  a 
trained  nurse  than  by  the  relatives. 

3.  Better  operations  can  be  performed  because  of  the 
general  gas  anesthetic,  thus  reducing  the  length  of  treat- 
ment, and  necessitating  fewer  second  operations. 

There  are  12  very  serious,  complicated  cases  of  hand 
infections  from  this  series  which  are  not  included  in  the 
above  table,  as  these  were  first  given  home  treatment, 
usually  by  their  family  physician,  and  later,  as  a  final 
resort,  came  under  our  care  at  the  hospital.  The  serious 
results  of  this  delayed  treatment  are  conclusively  demon- 
strated by  the  following  chart: 

Serious  Complicated  Cases  Treated  at  Home  and  Taken  to  Hospital 

AS  Final  Resort. 

Total  number 12 

Opened 12 

Total  loss  of  time  from  work 379  days 

Average  loss  of  time,  per  case  .    ■ 31.5  days 

Permanent  disability,  loss  of  function  or  member     ...  5 

First  joint  index  finger  right  hand  stiflf    .... 

First  and  third  fingers  right  hand  flexed  and  stiff   . 

Four  fingers  right  hand  slightly  flexed  and  stiff 

Index  finger  left  hand  amputated 

Index  finger  right  hand  amputated 

Deaths 0 

All  of  the  cases  in  this  group  neglected  prophylactic 
measures  at  the  time  of  the  minor  injury;  a  few  were  given 
first  aid  by  fellow  employes,  as  attempted  removal  of  a 
splinter  from  the  hand,  in  which  case  a  portion  of  it  was 
left  in;  all  reported  to  the  doctor  from' three  days  to  one 
month  after  receiving  their  injuries;  and  seven  were  given 


DIAGNOSIS  OF  LOCATION  OF  PUS  381 

office  treatment  by  their  family  physicians  for  a  few  days 
before  being-  sent  to  the  hospital.  The  5  cases  of  per- 
manent deformities,  2  with  loss  of  fingers,  are  the  direct 
result  of  the  above  negligence. 


Fig.  129. — Deformed  hand — result  of  splinter  wound  at  base  of  thumb.  This 
deformity  resulted  from  trying  office  treatment  and  from  a  wrong  diagnosis  of 
the  location  of  the  pus.  The  middle  palmar  space  was  opened,  when  the  thenar 
space  was  involved.  As  a  result  the  middle  palmar  space  and  ulnar  bursa  both 
became  infected.  No  pus  was  found  on  opening  middle  palmar  space.  Twenty- 
four  hours  later  patient  entered  hospital,  and  through-and-through  drainage  of 
thenar  space  revealed  location  of  pus. 

ECONOMIC  VALUE  OF  PROPER  DIAGNOSIS  OF  LOCATION  OF  PUS 

AND  PROPER  SURGICAL  INTERFERENCE  IN  HAND 

INFECTIONS. 

A  classification  of  the  various  types,  as  to  location,  of 
the  41 1  cases  of  hand  infections  which  were  serious  enough 
to  cause  disability  will  give  the  relative  frequency  of  the 
involvement  of  the  different  spaces. 

I.  The  types  of  hand  infections,  named  in  their  order  of 
frequency,  which  were  given  ambulatory  treatment : 

(a)  Paroiiychia 90 

(b)  Superficial  or  subepithelial  abscesses 72 

(c)  Abscesses  in  superficial  connective-tissue  spaces — cellulitis  of 

hand 45 

{d)  Carbuncular  infections 20 

(e)   Lymphangitis  of  arm  from  hand  injury     .......  13 

(/)    Felons 10 

(g)  Collar-button  abscesses  (distal  edge  of  palm) 3 

Total 253 


382  HAND  INFECTIONS  AMONG  EMPLOYES 

II:  The  types  of  hand  infections,  named  in  their  order 
of  frequency,  which  were  given  hospital  treatment: 

(a)  Lymphangitis  of  arm  from  hand  injuries 59 

(b)  Felons 24 

(c)  Tenosynovitis 24 

(d)  Abscesses  in  superficial  connective-tissue  spaces — cellulitis  of 

hand 14 

(e)  Collar-button  abscesses 7 

(/)    Carbuncular  infections 5 

(g)   Middle  palmar  space  infections 5 

ih)  Paronychia 3 

(i)    Thenar  space  infections 3 

(./')    Hypothenar  space  infections 2 

Total 146 

III.  The  twelve  very  serious  cases  where  active  treat- 
ment was  adopted  late  were  characterized  by  having  more 
than  one  space  involved,  or  some  other  form  of  complica- 
tion, as  follows: 

(a)  Diffuse  cellulitis  of  hand  and  arm  and  general  sepsis. 
(h)   Middle  palmar  space  and  ulnar  bursa. 
(c)   Tenosynovitis  and  necrosis  of  bone  of  index  finger. 
{d)  Tenosynovitis  and  multiple  abscesses  of  arm. 
(e)    Diffuse  cellulitis  of  hand  and  arm. 

(/)    Tenosynovitis,  middle  palmar  abscess,  and  necrosis  of  bone. 
(g)   Thenar  space,  middle  palmar  space  and  ulnar  bursa.     (Fig.  129.) 
(It)  Tenosynovitis  and  middle  palmar  space. 

(i)    Superficial  abscess  of  hand,  lymphangitis  and  axillary  abscess. 
(7)    Superficial   abscess  of  hand,   lymphangitis,   axillary  abscess,   and  sub- 
clavicular and  subscapular  abscess  of  chest-wall  and  general  sepsis. 
{k)  Lymphangitis,  axillary  abscess  and  subclavicular  abscess  of  chest-wall. 
(/)    Lumbrical  space  abscess  and  necrosis  of  bone. 

CONCLUSIONS. 

In  dealing  with  this  question  of  hand  infections,  the 
student  and  the  surgeon  alike  must  recognize  that  he  is 
dealing  with  a  great  economic  problem  and  that  much 
depends  on  his  ability  to  cope  with  it  properly.  From 
the  viewpoint  of  the  infected  individual,  his  future  earning 
capacity  is  often  at  stake  and  this  can  be  materially 
affected  if  poor  functional  results  are  obtained.     With 


HAND  INFECTIONS  AMONG  EMPLOYES  383 

more  and  more  States  enacting  employes  compensation 
laws,  industries,  both  large  and  small,  are  held  responsible 
for  employes  accidents  and  resulting  complications.  Thus 
by  the  prevention  and  proper  treatment  of  such  a  ])reva- 
lent  condition  as  hand  infections,  the  surgeon — and 
especially  the  company  surgeon — is  able  to  save  these 
industries  a  great  financial  loss.  The  wise  employer  is 
beginning  to  recognize  the  retro-active  results  of  the 
proper  medical  and  surgical  care  of  his  employes,  so  that 
there  is  a  growing  demand  for  properly  trained  company 
surgeons. 

In  hand  infections,  therefore,  the  company  surgeon 
must  recognize  that  in  order  to  give  the  best  results 
from  every  viewpoint,  the  prevention  and  treatment 
must  include: 

1.  Removal  of  external  causes  for  accidents — found  in 
the  working  place. 

2.  Removal  of  predisposing  causes  for  infections — 
found  in  employes. 

3.  The  sending  of  every  injured  employe  to  the  doctor 
for  immediate  dressing. 

4.  The  use  of  tincture  of  iodine  at  once  as  a  prophy- 
lactic measure. 

5.  The  treatment  of  hand  infections  as  a  serious  surgical 
condition  from  their  inception,  and  whenever  indicated, 
the  adoption  of  hospital  treatment  early. 

6.  The  proper  and  early  diagnosis  of  the  type  and 
nature  of  the  infection  and  the  exact  location  of  the  pus. 

7.  A  proper  incision  of  the  abscess  in  order  to  establish 
adequate^  drainage  and  yet  not  spread  the  infection  to 
other  spaces. 


SECTION    IV. 
ALLIED  INFECTIONS. 


CHAPTER  XXVI. 

ERYSIPELAS,  ERYSIPELOID,  GAS-BACILLUS 
INFECTION,  ANTHRAX. 

ERYSIPELAS. 

Erysipelas  may  appear  in  two  types:  first  an  uncom- 
plicated cutaneous  lymphangitis  corresponding  to  the 
picture  seen  upon  the  face,  and  second,  as  a  cutaneous 
lymphangitis,  complicated  with  a  subcutaneous  lym- 
phangitis. This  latter  type  is  more  common  in  the  hand. 
The  former,  the  rarer  type,  is  that  of  the  typical  erysipelas 
as  seen  upon  the  face  with  the  brawny  induration  con- 
fined to  the  skin  and  outlined  by  a  distinct  border.  The 
deep  purple-red  skin  may  have  blebs  upon  it.  The 
second  type  is  the  accompaniment  of  the  severe  sub- 
cutaneous lymphangitis,  and  has  been  discussed  on  pages 
328  and  355. 

The  treatment  of  erysipelas  proper  is  clearly  that  of  a 
lymphangitis  which  also  has  been  discussed  (see  pp.  346 
and  351).  No  special  applications,  such  as  carbolic  acid, 
ichthyol,  salicylic  acid,  can  be  considered  to  be  of  special 
value.  In  the  superficial  type  the  usual  hot,  moist  dress- 
ings may  be  used;  the  treatment  of  the  severer  types 
referred  to,  which  are  often  called  gangrenous  erysipelas 
or  gangrenous  cellulitis  by  surgeons,  has  been  discussed 
on  page  355. 


ERYSIPELOID  385 

ERYSIPELOID. 

This  is  a  conclition  seen  most  commonly  upon  the 
fingers  and  which  may  be  mistaken  for  true  erysipelas. 
The  earlier  writers  have  described  it  under  the  title  of 
chronic  erysipelas,  or  erythema  migrans.  Rosenbach 
designated  the  condition  erysipeloid,  a  name  which  has 
been  accepted  by  the  profession. 

It  commonly  has  its  origin  in  some  slight  wound,  and 
is  most  often  seen  in  those  handling  fish  and  oysters  or 
cheese  and  herring.  Therefore,  it  is  found  among  fisher- 
men, butchers,  cooks,  etc.  Gilchrist  has  described  his 
findings  in  over  300  cases  which  originated  in  crab  bites. 
He  thought  the  condition  was  due  to  a  ferment  injected 
by  the  crab  bite,  and  not  to  a  special  organism.  Rosen- 
bach  described  a  cladothrix-like  organism  as  the  cause,  and 
this  finding  was  later  confirmed  by  Ohlemann.  It  is  an 
irregular  round  organism,  developing  into  threads  in  old 
cultures.  Pathologically  one  finds  an  invasion  of  the 
corium  with  pdlynuclear  leukocytes  and  a  massing  of 
lymphoid  cells  about  the  bloodvessels. 

Symptoms. — Following  a  slight  injury,  generally  upon 
the  fingers,  the  skin  becomes  swollen,  painful,  and  of  a 
deep  bluish  color.  There  is  some  local  burning  and 
itching,  but  no  fever  or  any  general  reaction.  The  infec- 
tion extends  gradually  with  a  sharp  line  of  demarcation 
up  the  finger  into  the  hand  rarely  as  high  as  the  middle, 
but  it  may  involve  the  adjacent  fingers.  As  it  extends, 
the  older  area  becomes  pale.  A  lymphangitis  of  a  very 
resistant  type  may  develop.  There  are  no  papules, 
vesicles,,  or  suppuration.  The  disease  lasts  from  one  to 
four  weeks,  varying  with  the  treatment. 

Treatment. — Lexer  advises  immobilization  by  a  splint 
for  from  two  to  four  days,  accompanied  by  applications 
of  vaseline.  If  movement  begins  too  early,  the  trouble 
will  reappear.  Others  recommend  25  per  cent,  salicylic 
acid  ointment  followed  by  a  bland  oil. 
25 


386  ERYSIPELAS,  ERYSIPELOID,  A  Mil  RAX 

GAS-BACILLUS  INFECTION. 

Under  this  title  many  conditions  are  included  which 
have  in  ])ast  years  been  described  by  many  titles  such  as 
j^aseous  phlegmon,  emphysematous  gangrene,  malignant 
edema,  etc.  It  is  probable  that  several  distinct  types 
are  here  included. 

Weinberg  and  Seguin  have  studied  91  patients  suffering 
from  this  condition;  all  but  two  occurred  in  war  wounds. 
They  were  from  all  parts  of  the  front. 

No  cases  were  caused  by  aerobes  alone.  In  24  cases  the 
anaerobes  were  unaccompanied  by  areobes;  in  67  they 
were  found  in  symbiosis  with  one  or  more  aerobe.  In 
37  cases  there  was  but  a  single  anaerobe;  in  54  there  were 
more  than  i. 

According  to  their  frequency,  the  anaerobes  take  pre- 
cedence as  follows:  Bacillus  aerogenes  capsulatus  in  70 
cases  (77  per  cent.),  Bacillus  edematiens  in  31  cases  (34 
per  cent.).  Bacillus  sporogenes  in  25  cases  (27  ])er  cent.). 
Bacillus  fallax  in  15  cases  (16.5  per  cent.).  Bacillus  of 
malignant  edema  in  12  cases  (13  per  cent.),  Bacillus 
tetani  in  9  ca.ses  (10  per  cent.).  Bacillus  histolyticus  in  8 
cases  (9  per  cent.).  Bacillus  aerofaetidus  in  5  cases  (5.5 
per  cent.),  Bacillus  putrificus  in  2  cases  (2  per  cent.), 
B^icillus  bifermentans  in  2  cases  (2  per  cent.),  Bacillus 
Ghon-Sachs  1 1  in  i  case  (i  per  cent.),  and  Bacillus  tertius 
in  I  case  (i  per  cent.). 

The  authors  call  attention  especially  to  the  frequency 
of  four  organisms,  two  of  which.  Bacillus  aerogenes  capsu- 
latus and  Bacillus  sporogenes,  were  already  known  at  the 
beginning  of  the  war,  and  the  other  two,  of  which  Bacillus 
edematiens  and  Bacillus  fallax,  have  been  discovered  by 
the  authors. 

All  writers  now  agree  that  Bacillus  aerogenes  capsulatus 
is  the  organism  most  commonly  associated  with  the 
infection.     The  importance  of  Bacillus  edematiens  (found 


GAS-BACILLUS  INFECTION  :}87 

in  a  little  mure  than  one-third  of  the  cases;  lies  rather  in 
the  fact  of  the  seriousness  of  most  of  the  cases  in  which 
it  is  concerned.  Of  the  aerobes  present,  streptococci 
appeared  in  about  40  per  cent,  of  the  cases;  it  seriously 
affected  the  prognosis.  Diplococci  (enterococci)  appeared 
in  33  per  cent,  of  the  cases.  Staphylococci  were  some- 
what less  frequent. 

Taylor  believes,  on  the  other  hand,  that  there  is  but  one 
distinct  species — Bacillus  aerogenes  capsulatus — respon- 
sible for  nearly  all  cases  of  gas  gangrene.  Bacillus  of 
malignant  edema  is  the  only  other  gas-producing  organism 
that  may  cause  extensive  lesions  in  the  muscles,  but  this 
bacillus  rarely,  if  ever,  gives  rise  to  extensive  gaseous 
phlegmons.  It  is,  however,  frequently  found  in  the 
wound  itself.  The  frequent  occurrence  of  subcutaneous 
edema,  the  author  believes,  is  due  to  the  obstruction  of  the 
deep  lymphatics  and  veins  by  intramuscular  pressure  and 
not  to  this  organism.  Simonds,  in  his  monographs  on 
the  Bacillus  welchii  published  in  191 5,  collected  175  cases 
of  gas  gangrene  or  gas  phlegmon  due  to  Bacillus  aerogenes 
capsulatus,  occurring  before  the  war  with  a  mortality  of 
about  45  per  cent.  This  high  figure  indicates  the  import- 
ance of  this  organism  in  gaseous  infections  in  civil  life. 

The  infection  may  begin  with  the  slightest  wound, 
but  more  often  it  is  found  with  severe  injuries  in  which 
dirt  has  been  ground  into  the  tissues.  It  has  been  my 
fortune  to  see  three  patients  in  civil  life  with  gas  bacillus 
infection  in  the  arm,  two  of  which  began  from  ^■ery 
insignificant  injuries,  and  the  third  followed  a  compound 
fracture  oi  a  finger. 

Experience  in  the  late  war  has  decided  many  of  the 
questions  concerning  this  condition. 

The  clinical  types  of  gangrene  may  be  classified  as  (i) 
classic,  (2)  toxic,  and  (3)  mixed. 

Classic  Gaseous  Gangrene. — This  is  characterized 
as  having  the  following  symptorns:     Abundant  gas  pro- 


388  ERYSIPELAS,  ERYSIPELOID,  ANTHRAX 

duction,  considerable  gaseous  crepitation,  often  super- 
ficial, bronze  tint  on  the  skin,  blebs,  and  in  fatal  cases 
septicemia  often  setting  in  a  few  hours  before  death. 
Of  this  type  of  gaseous  gangrene  it  is  believed  that  the 
Bacillus  aerogenes  capsulatus  and  Bacillus  of  malignant 
edema,  either  singly  or  in  symbiosis,  are  most  often  the 
causative  agents.  Sometimes  an  extremely  toxic  organ- 
ism like  the  Bacillus  edematiens  may  be  associated  with 
the  other  agents  in  this  type  of  the  disease. 

Toxic  Gaseous  Gangrene. — This  type  differs  from  the 
classic  in  that  progressive,  spreading  edema  masks  the 
infiltration  of  the  tissues  with  gas,  and  together  with 
general  symptoms  of  intoxication,  constitutes  the  most 
apparent  outward  sign  of  the  infection.  There  is  rarely 
septicemia,  even  in  fatal  cases.  So  different  is  this  type 
from  the  classic,  that  surgeons  tend  to  associate  it  rather 
with  streptococcic  infections  (white  erysipelas)  than  with 
genuine  gaseous  infections.  It  is  thought  that  the 
Bacillus  edematiens  is  the  causative  agent  of  this  form  of 
the  disease,  although  the  Bacillus  aerogenes  capsulatus 
sometimes  produces  similar  results. 

Mixed  Gaseous  Gangrene. — This  form  includes 
cases  which  present  not  only  the  complex  flora  (Bacillus 
edematiens  and  Bacillus  aerogenes  capsulatus)  but  also  the 
leading  symptoms  of  the  two  preceding  varieties  (classic 
and  toxic).  These  symptoms  are  usually  edema  and 
gaseous  crepitation. 

Wallace  studied  the  subject  clinically  at  a  casualty 
clearing  station,  and  came  to  the  following  conclusions: 

1.  It  is  rare  to  meet  gas  gangrene  without  a  muscle 
injury. 

2.  It  is  chiefly  a  disease  of  the  muscles  and  is  rarely 
dangerous  unless  muscle  is  involved. 

3.  The  lesion,  in  its  early  stages,  may  be  described  as  a 
longitudinal  one,  running  up  and  down  the  wounded 
muscles  from  the  seat  of  the  lesion.  Muscles  and  groups 
of  muscles  are  involved  while  others  escape. 


GAS-BACILLUS  INFECTION  :m 

4.  It  is  rare  to  find  all  the  muscles  of  a  sei>ment  of  a 
limb  involved,  save  in  a  segment  distal  to  one  in  which  the 
main  blood  supply  has  been  cut  off.  Thus  the  whole 
leg  dies  and  becomes  gaseous  when  the  femoral  artery 
has  been  blocked  in  the  thigh. 

5.  The  muscles  affected  are,  in  the  first  instance,  the 
wounded  ones.  If  the  pressure  caused  by  the  disease  is 
relieved,  the  gangrene  will  most  probably  be  confined  to 
these  muscles,  but  if  the  pressure  is  not  relieved  the  other 
muscles  may  so  have  their  blood  supply  checked  as  to  fall 
victim  to  the  infection. 

6.  Muscles  contained  in  rigid  compartments,  such  as 
the  anterior  tibial  group,  are  especially  prone  to  die  if 
wounded. 

7.  There  is  but  little  tendency  for  the  infection  to  pass 
from  one  muscle  to  another.  This  is  well  shown  in 
amputation  stumps,  where  one  muscle  dies  and  becomes 
gaseous,  while  the  rest  of  the  cut  muscles  remain  healthy. 

8.  The  infection  is  farther  advanced  in  the  muscles 
than  in  the  intermuscular  areolar  planes. 

9.  The  muscles  become  resonant  from  the  pressure  of 
gas  long  before  they  become  crepitant  to  the  finger, 
though  this  phenomenon  may  be  perceptible  at  an  early 
date  by  means  of  the  stethoscope. 

10.  The  presence  of  gaseous  crepitation  does  not  neces- 
sarily mean  microbic  infection. 

11.  Crepitation  is  usually  a  comparatively  late  phe- 
nomenon and  is  due  to  the  escape  of  gas  into  the  areolar 
and  subcutaneous  tissue. 

12.  In  an  infected  limb,  a  vascular  lesion  will  be  fol- 
lowed by  the  death  of  the  muscle  or  the  muscle  group, 
which  death  would  not  have  followed  in  an  uninfected 
limb.  It  is  believed  that  the  pressure  produced  by  the 
gas  so  raises  the  tension  in  the  limb  as  finally  to  arrest 
the  circulation. 

13.  In  an  infected  limb  there  are  several  conditions  of 


390  ERYSIPELAS,  ERYSIPELOID,  ANTHRAX 

llie  muscles:  {a)  Normal  j)iiri)lc  red  contractile  muscle 
which  may  or  ma>'  not  be  infected  as  juds^ed  by  cultural 
experiments,  {b)  Dead,  non-contractile,  non-crepitant 
muscle  which  has  a  peculiar  red  color  and  is  less  trans- 
lucent than  normal  muscle,  (c)  Dead,  non-contractile, 
creptitant  muscle  which  has  the  same  appearance  as  the 
last,     id)  Brown,  black,  or  diffluent  muscle. 

(Muscle  dead  from  the  cutting  of  the  blood  supply  is 
a  purplish  .brown  and  its  naked-eye  appearance  quite 
different  from  {b)  and  (c) ). 

Upon  his  clinical  experience  he  establishes  the  following 
four  conclusions  regarding  treatment: 

(a)  All  pressure  or  other  hindrance  to  circulation  should 
be  avoided  and  especially  that  all  hemorrhages  and 
hematomata  should  be  hunted  out  and  corrected.  In 
cases  involving  the  injury  or  thrombosis  of  great  vessels 
he  urges  that  an  attempt  be  made  to  suture  rather  than 
resort  to  ligature. 

(b)  In  considering  amputation  it  is  well  to  remember 
that  only  the  wounded  muscle  is  likely  to  be  infected  with 
gaseous  gangrene,  and  that  excision  or  the  ablation  of 
this  muscle  usually  suffices  to  arrest  infection.  This  is 
not  so  easily  accomplished,  however,  in  the  thigh  as  in  the 
leg,  in  which  case  it  is  fairly  easy  to  save  the  limb  by  the 
ablation  of  the  anterior  tibial  group.  The  same  holds 
true  for  the  muscles  of  the  forearm.  The  brick  red  color 
and  the  non-contractibility  will  show  at  once  which 
muscles  are  past  saving. 

(c)  When  gas  gangrene  occurs  in  a  segment  of  a  limb 
distal  to  the  segment  wounded  it  nearly  always  means 
that  the  main  artery  is  blocked  and  amputation  of  the 
gangrenous  segment  is  the  only  course. 

{d)  He  warns  against  taking  the  extent  of  crepitation 
of  the  skin  as  an  indication  for  amputation,  for  it  may  not 
necessarily  indicate  a  state  of  infection  requiring  such 
drastic  treatment.     The  surgeon  before  deciding  should 


GAS-BACILLUS  INFECTION  391 

determine  aceuralely  the  exact  eoiulition  of  the  nuiscles 
and  the  number  involved.  Otherwise  many  hmbs  may 
be  sacrificed  when  the  removal  of  only  a  single  muscle 
might  serve  to  check  the  infection. 

Bull  and  Pritchett  and  others  have  prepared  sera  both 
as  a  prophylactic  and  curative  measure  w^ith  some  appar- 
ent success. 

The  condition  is  too  grave  for  any  half-way  measure. 
The  cutaneous  incisions  should  be  extensive  and  left 
unsutured.  Injured  or  infected  muscles  should  be  excised. 
If  under  this  treatment  there  is  any  tendency  to  spread 
in  the  next  twelve  hours,  amputation  should  be  advised. 
In  the  more  virulent  type  as  shown  by  the  local  and 
systemic  reaction  no  time  should  be  wasted  in  palliative 
measures,  for  the  patient  rapidly  passes  into  the  stage  of 
systemic  infection  or  toxemia,  from  which  he  will  not 
recover  even  with  amputation.  One  may  say,  therefore, 
that  amputation  should  be  performed  in  case  of  doubt. 
It  should  be  done  well  proximal  to  the  infection,  so  as  to 
make  incisions  in  healthy  tissue,  and  the  stump  should  be 
left  open  for  secondary  suture  after  we  are  certain  that  the 
process  is  under  control. 

My  own  experience  in  civil  practice  in  three  cases  bears 
out  these  statements.  In  the  first  case  seen,  amputation 
was  performed  at  once  and  the  patient  recovered  promptly. 
The  gaseous  infection  had  spread  well  into  the  arm. 
The  amputation  was  performed  at  the  upper  third  of  the 
humerus.  In  the  second  case  seen  in  consultation,  wide 
incisions  were  made  which  were  further  increased  upon  the 
next  day.  The  patient  was  not  seen  by  me  subsequent  to 
the  first  day.  I  am  informed,  however,  that  the  gaseous 
infections  subsided,  and  a  secondary  infection  began  from 
which  the  patient  succumbed  at  the  end  of  three  w^eks. 
The  third  case  seen  by  me  was  one  in  which  the  patient  had 
suffered  a  slight  abrasion  of  the  middle  finger  of  the 
left  hand.     I  saw  him  at  the  end  of  the  fifth  day,  when 


392  ERYSIPELAS,  ERYSIPELOID,  ANTHRAX 

the  systemic  condition  showed  the  patient  to  l)e  sufferin<>^ 
from  a  marked  toxemia.  Tlie  whole  arm  had  a  l)luish- 
black  color,  was  swollen,  and  covered  by  l)lel)s.  The  arm 
was  amputated  by  an  able  surgeon  at  once,  but  the 
patient  succumbed  from  his  toxemia  within  a  few  hours. 

ANTHRAX. 

Anthrax  is  not  common  in  the  United  States,  although 
sporadically  it  may  appear  in  various  sections.  The 
frequency  of  lesions  upon  the  hand  and  arm  is  given  by 
Koch,  in  a  series  of  923  cases,  as  40  per  cent.  Personally, 
my  experience  is  limited  to  one  case.  The  description 
of  the  condition  which  I  append  is  modified  from  that 
given  in  Frazier's  excellent  description  of  the  disease. 
No  attention,  of  course,  is  here  given  to  the  pulmonary 
and  intestinal  types.  When  the  disease  is  implanted 
upon  the  hand  or  forearm  of  those  having  to  deal  with 
hides  and  other  sources  of  infection,  we  note  an  elevated 
pustule,  5  mm.  to  several  centimeters  in  diameter,  with  a 
depressed  central  scab.  The  corium  and  papillary  body 
become  infiltrated  with  a  serocellular  exudate  and  with 
bacilli.  The  perivascular  and  connective-tissue  spaces 
become  filled  with  leukocytes,  and  the  pressure  of  this 
serous  and  cellular  infiltrate,  together  with  the  toxins  of 
the  bacteria,  cause  the  central  coagulation  necrosis, 
though  suppuration  does  not  occur  unless  there  is  a 
mixed  infection.  When  the  serocellular  exudate  extends 
upward  to  the  superficial  epithelium,  it  elevates  the 
latter  and  produces  the  typical  vesiculation.  In  the 
edematous  variety  the  swelling  is  due  to  the  diffuse 
serocellular  infiltrate  and  to  the  effect  of  the  bacteria 
blocking  or  inducing  coagulation  in  the  capillary  vessels. 

The  lesion  may  be  transferred  to  other  parts  of  the  arm 
or  body,  especially  the  face,  by  scratching  the  lesion  and 
then  the  secondarily  infected  part.  Wherever  the  lesion 
occurs  we  note  that  from  a  few  hours  to  some  days  after 


ANTHRAX  393 

the  inoculation  some  itchini^  and  Ijurning  are   felt,    and 
upon  inspection  a  small  papule  with  a  central  bluish  point 
is  seen.     A  few  hours  later  the  papule   becomes  vesicu- 
lated,  contains  a  brownish,  sanguineous  fluid,  and  may  be 
scratched  ofT  by  the  patient.     The  surrounding  tissues 
become  red,  indurated,  and  pufTy,  and  later  purplish  and 
gangrenous   in  appearance,   although   there   may   be   no 
indication  of  suppuration.     Pain  now  ceases,  and  beyond 
malaise,  nausea,  slight  fever,  and  muscular  or  joint  pains, 
there  may  be  no  other  constitutional  efifect.     A  vesicu- 
lar areola  limited  in  extent  is  soon  observ^ed  about  the  pus- 
tule, containing  serohemorrhagic  fluid;  the  pustule  ma}^ 
undergo  necrosis,  the   area  of  necrosis  rarely  exceeding 
3  cm.  in  diameter.     In  about  ten  days,  in  favorable  cases, 
a  line   of   demarcation  forms    about  the  eschar,   which 
"floats  off,"  leaving  a  defect  to  heal  by  granulation.     In 
more  severe  cases  the  edematous  swelling  about  the  pus- 
tule may  be  very  extensive  and  erysipelatous  in  appear- 
ance, associated  w4th  a  lymphangitis  and  lymphadenitis 
with  hard  and  tender  lymph  nodes.    The  vesicles  become 
bullae,  contain  a  bloody  fluid,  and  the  ultimate  suppura- 
tive and  gangrenous  process  may  involve  areas  as  large 
as  the  entire  half  of  the  face.     In  these  severe  cases  the 
constitutional  symptoms  are  marked,  resembling  those  of 
cholera,  with  great  prostration  and  depression,  a  weak, 
rapid  pulse,  often  icterus,  diarrhea,  delirium,  and  coma. 
In  the  parts  where  there  is  considerable  loose  areolar 
tissue,   as  the  eyelids,   neck,   and  forearm,   great  edema 
may  be  seen.     Here,  instead  of  the  characteristic  changes 
described -above,  the  area  may  have  a  well-defined  border 
without  vesiculation,  redness,  or  gangrene.  There  may  be 
little  or  no  pain,  even  in  those  cases  ending  fatally. 

The  diagnosis  must  be  made  from  the  furuncles  and 
carbuncles.  The  careful  surgeon  will  at  once  note  that 
the  lesion  is  essentially  different  from  these,  and  will  by 
smears  and  culture  determine  the  presence  of  the  anthrax 
bacillus. 


394  ERYSIPELAS,  ERYSIPELOID,  ANTHRAX 

The  statistics  as  to  the  niortaht)  \ar\'  iireatly,  being 
from  6  to  30  per  cent.  Koch  collected  14 13  i)uhlished 
cases,  with  a  mortality  of  32  per  cent. 

The  treatment  of  anthrax  should  consist  essentially  in 
the  administration  of  serum,  in  the  application  of  certain 
bacteriological  agents  and  in  the  use  of  large  amounts  of 
water  internally,  and  possibly  in  the  excision  of  the  pustule; 
if  recognized  early  the  serum  should  be  administered  sub- 
ciitaneously  and  the  pustule  should  be  excised  only  when 
the  surrounding  tissues  are  not  very  edematous,  taking  the 
precaution  to  cauterize  the  exposed  surfaces  with  carbolic 
acid  or  the  actual  cautery.  If  the  edema  is  marked, 
absolute  rest  of  the  part  should  be  enjoined  and  local  hot 
antiseptic  fomentations,  such  as  bichloride  of  mercury, 
a])plied.  The  serum  has  no  deleterious  effects,  and  in  the 
hands  of  its  originator  and  others,  especially  in  Italy  and 
England,  the  results  substantiate  the  claims  which  have 
been  made.  A  serum  may  be  obtained  from  the  United 
States  Bureau  of  Animal  Industry,  Washington,  D.  C,  or 
pharmaceutical  houses.  It  assists  in  the  destruction  of 
the  bacilli  before  they  become  so  numerous  that  their 
destruction  by  the  bodily  defences  increases  the  danger 
of  fatal  poisoning  from  the  toxins  set  free  by  the  disin- 
tegration of  the  bacilli.  When  the  serum  cannot  be 
obtained,  and  when  excision  is  impracticable,  injections  of 
carbolic  acid  (5  per  cent.)  should  be  tried,  introducing  the 
needle  at  several  points  along  the  margin  of  the  pustule 
and  infiltrating  the  base  of  the  pustule  and  surrounding 
healthy  tissue.  These  injections  may  be  repeated  fre- 
quently. The  constitutional  symptoms  must  be  met  by 
appropriate  and  supportive  measures. 

Scholl  has  reported  upon  the  results  in  51  patients 
treated  at  the  Massachusetts  General  Hospital.  Of 
these  13  died.  Of  9  treated  surgically  4  died  and  of  42 
treated  medically  only  3  died.  On  the  basis  of  these 
results    he    urges    strongly    against    surgical    treatment 


ANTHRAX  395 

helicvini;    that    the   incision   opens    the   lymphatics    to   a 
further  spread  of  the  bacteria. 

It  has  been  my  fortune  to  meet  with  (jnly  (Mie  case  of 
anthrax.  That  occurred  in  a  man,  aged  thirty-five  years, 
who  worked  in  the  Chicago  stockyards.  He  appHed  at  the 
Cook  County  Hospital  for  treatment,  and  I  regret  to  say 
that  the  records  of  the  case  cannot  be  secured  at  the 
present  time.  The  lesion  was  upon  the  left  forearm  and 
presented  the  characteristic  gangrenous  center.  He  was 
treated  by  local  antiseptics  and  made  a  prompt  recovery. 


SECTION   V. 

COMPLICATIONS  AND  SEQUELS  OF 
INFECTIONS  OF  THE  HAND. 


CHAPTER  XXVII. 

FOREARM   INVOLVEMENT  FROM   INFECTIONS 

OF  THE  HAND— PATHOLOGY  AND 

DIAGNOSIS. 

Forearm  involvement  occurs  in  two  forms — that 
associated  with  lymphangitis  and  that  following  tendon- 
sheath  infection  of  the  flexor  tendons  and  abscesses  in  the 
palm.  These  two  forms  have  been  touched  upon  in 
general  in  discussing  these  infections  in  the  preceding 
chapters.  The  pathology  and  localization  is  essentially 
different,  as  it  arises  from  the  two  sources.  I  refer,  of 
course,  to  suppurative  involvement,  and  have  no  refer- 
ence to  the  edema  which  always  occurs  with  any  infection. 
At  the  risk  of  some  repetition,  I  shall  review  the  subject 
in  general,  so  as  to  give  a  composite  picture. 

SUBCUTANEOUS  ABSCESSES. 

That  form  due  to  lymphatic  involvement  of  superficial 
origin  has  been  referred  to  on  page  313.  We  may  have  a 
secondary  involvement  upon  both  the  flexor  and  extensor 
surfaces.  Upon  the  flexor  surface  we  find  a  localization 
just  above  the  annular  ligament  in  many  cases  oF  deep 
infection  of  the  hands,  particularly  those  cases  showing 
an  ulnar  bursitis.  They  are  characterized  by  redness 
and  slight  induration  over  an  area  two  or  three  inches  in 


DEEP  ABSCESSES  397 

length  at  the  lower  end  of  the  forearm.  The  diagnosis 
is  not  difficult,  the  only  thing  to  be  borne  in  mind  being 
that  the  surgeon  should  understand  its  origin  and  should 
not  desist  from  dealing  with  the  extension  under  the 
tendons  from  a  rupture  of  its  synovial  sheath,  since  there 
is  no  connection  between  these  pockets,  and  draining  the 
superficial  pocket  does  not  drain  the  deeper  and  more 
important  focus. 

Besides  this  well-diflferentiated  localization,  small  foci 
may  develop  along  the  lines  of  any  lymphatic,  either  on 
the  flexor  or  dorsal  surface.  Care  should  be  taken  not 
to  mistake  these  uncommon  localizations  for  the  acute 
non-suppurative  inflammation  of  the  lacunae  (see  p.  314). 
Again,  localizations  may  take  place  about  the  glands  of 
the  epitrochlear  region,  as  has  been  described  in  Chapter 
XX. 

The  most  important  subcutaneous  accumulation 
associated  with  lymphatic  infection  occurs  upon  the 
dorsum  of  the  forearm.  This  condition,  characterized 
by  a  brawn}'  induration  of  the  entire  dorsum,  with 
necrosis  and  sloughing  of  the  subcutaneous  tissue,  is  one 
of  the  gravest  complications  met  with  in  hand  infections. 
A  full  discussion  may  be  found  in  Chapters  XX  and  XXI. 

DEEP  ABSCESSES. 

The  deep  involvement,  no  matter  what  the  origin, 
almost  always  is  found  upon  the  flexor  surface.  This 
most  commonly  arises  through  extension  by  rupture  of 
the  proximal  end  of  the  ulnar  or  radial  bursae  or  b}' 
extension  from  a  palmar  abscess.  This  is  with  great 
rarity  by  all  odds  the  most  important  question  we  have 
to  deal  with  when  considering  forearm  involvement.  It 
will  be  discussed  under  three  heads: 

I.  Cases  showing  forearm  abscesses  without  other 
complications. 


398  FOREARM  INVOLVEMENT 

2.  Cases  showing  forearm  involvement  with  carpal 
joint  involvement. 

3.  Cases  showing  forearm  involvement  with  secondary 
hemorrhage. 

Forearm  Involvement:  Abscess  Formation  without  Other 
Complications. 

Location  of  the  Abscesses. — It  has  been  the  habit 
of  surgeons  and  writers  dealing  with  this  subject  to  speak 
of  these  abscesses  in  a  general  way  only,  and  to  suggest 
drainage  through  the  volar  surface  between  the  tendons 
and  muscles.  In  my  earlier  cases  I  was  struck  with  the 
long  convalescence,  the  repeated  incisions,  and  the  inade- 
quate drainage  owing  to  the  rapid  closure  of  the  sinuses 
through  the  muscular  bodies.  Therefore  a  careful  study 
of  the  anatomy  of  the  forearm  was  undertaken  both  by 
dissection  of  serial  sections  and  by  experimental  injections 
made  through  the  various  tendon  sheaths  and  from  other 
sites  of  predilection  of  pus  in  the  hand.  By  this  I 
determined  the  probable  site  of  these  secondary  abscesses 
in  the  forearm.  These  experimental  and  anatomical 
deductions  were  verified  by  a  study  of  all  my  cases 
showing  this  complication,  as  well  as  an  extensive  review 
of  cases  reported  in  the  literature.  The  result  was 
beyond  expectation.  The  study  enables  the  surgeon  to 
prognosticate  before  operation  the  exact  location  of  pus 
in  the  forearm.  It  suggested  new  sites  for  drainage  which 
cured  patients  in  from  one  to  two  weeks  by  two,  or  at 
most  three,  primary  incisions,  who  by  the  older  procedures 
would  have  required  from  three  to  five  weeks,  with  the 
probability  of  many  complications. 

The  anatomical  and  experimental  work  I  have  de- 
tailed in  Chapter  X.  It  remains  for  me,  therefore,  to 
adduce  the  clinical  proof  of  its  correctness  and  suggest 
plans  of  treatment.     It  will  be  seen,  by  referring  to  Chap- 


ABSCESS  FORM /IT  ION  WITHOUT  COMPLICATIONS   399 

ter  X,  that  the  final  deduction  made  from  the  researches 
A\as  that  the  important  space  in  which  pus  would  be 
found  in  those  cases  where  the  infection  originated  in  the 
hand  had  the  following  boundaries:  It  lies  under  the 
flexor  profundus  digitorum  tendons  and  muscle.  About 
three  inches  up  on  the  forearm  the  pus  begins  to  invade 
the  intermuscular  septa,  passing  first  to  the  area  about  the 
median  nerv^e  and  later  to  the  area  about  the  ulnar 
artery  and  nerve.  Here  it  lies  between  the  flexor  carpi 
ulnaris  and  the  flexor  profundus.  This  is  about  four 
inches  up  on  the  forearm.  From  here  it  may  pass  toward 
the  elbow  along  the  vessels  and  nerves,  particularly  the 
median  ner^  e,  or  more  commonly  it  may  extend  distally 
along  the  ulnar  artery  under  the  flexor  carpi  ulnaris  and 
appear  subcutaneously  about  three  inches  up  on  the 
ulnar  side.  It  may  extend  downward  along  the  radial 
artery,  but  this  is  certainly  an  uncommon  termination. 
The  largest  part  of  the  space  is  about  two  inches  above 
the  wrist.  Its  most  superficial  parts  are  on  either  side 
just  volar  to  the  ulna  and  radius.  The  floor  of  the 
space  is  made  up  by  the  pronator  quadratus  at  the 
wrist  and  the  interosseous  septum  above.  The  space 
m.ay  hold  a  half-pint  or  more  of  fluid.  No  other  well- 
defined  space  is  present  except  that  comprising  the  sub- 
cutaneous tissue.  In  corroboration  of  this  statement, 
I  shall  make  excerpts  from  some  of  the  cases  that  have 
come  under  m^^  observation,  and  shall  add  a  few^  from  the 
reports  of  Tornier  and  Forssell  to  show  that  my  opinions 
are  unbiased.  That  there  may  be  no  question  as  to  the 
possibility  of  the  infection  having  arisen  sequentially  from 
a  carpal-joint  involvement,  those  cases  will  be  excluded 
and  only  uncomplicated  forearm  involvement  discussed. 
Altogether  I  have  now  had  over  60  patients  showing  this 
extension.  The  report  of  the  postmortem  in  Case  XXII 
may  also  be  noted  in  corroboration. 


400  FOREARM  INVOLVEMENT 

Case  XXV. — The  ulnar  bursa  was  opened  and  incision 
extended  to  the  middle  of  the  forearm,  exposing  an  abscess 
lying  mainly  under  the  flexor  profundus  digitorum. 

Case  XXVI. — The  flexor  side  of  the  forearm  was  swollen 
and  painful  to  the  upper  third,  incision  was  continued  from 
the  ulnar  bursa  on  the  forearm  toward  the  centre.  In  juxta- 
position to  the  nerves  and  bloodvessels  a  pocket  of  pus  was 
evacuated,  which  extended  between  the  flexor  sublimis  digi- 
torum and  the  flexor  profundus  digitorum,  and  lying  on  the 
interosseous  membrane  of  the  upper  half  of  the  forearm. 

Case  XXVII. — The  hand  and  forearm  were  swollen, 
incision  was  extended  from  the  ulnar  bursa  in  the  forearm 
and  the  flexor  muscles  were  separated  by  the  handle  of  the 
scalpel.  The  abscess  extended  along  the  interosseous  liga- 
ment to  within  a  hand's  breadth  of  the  elbow. 

Case  XXVIII. — Incision  was  made  opening  the  sheath 
of  the  flexor  longus  pollicis  and  up  to  the  annular  ligament; 
a  second  incision  was  made  into  the  same  sheath  above  the 
annular  ligament,  and  this  was  extended  along  the  lower  half 
of  the  forearm  over  the  radial  sources  of  the  flexor  sublimis 
digitorum.  Pus  was  found  along  the  flexor  longus  pollicis  and 
behind  the  flexor  profundus  digitorum  in  the  lower  third  of 
the  forearm. 

Case  XXIX. — A  large  amount  of  pus  Mas  shown  in  the 
lower  two-thirds  of  the  forearm  lying  between  the  flexor  sub- 
limis digitorum  and  the  flexor  carpi  ulnaris,  below  the  flexor 
profundus,  which  was  entirely  evacuated  by  a  single  incision 
upon  the  ulnar  side  above  the  wrist-joint. 

In  the  following  case  there  was  a  neglected  tendon- 
sheath  infection  on  the  dorsum.  These  cases  are  ex- 
tremely uncommon,  since  they  are  generally  only  local 
abscesses  without  extension. 

Case  XXX. — An  infection  extended  upon  the  back  of  the 
forearm;  after  two  superficial  abscesses  had  been  opened,  it 
was  noted  some  days  later  that  there  was  a  painful  swelling 
on  the  dorsal  ulnar  side  of  the  forearm;  this  was  incised  as 
far  as  the  fascia  without  freeing  any  pus.  A  pocket  was 
found,  however,  under  the  dorsal  annular  ligament  extending 
into  the  otherwise  healthy  muscle  above. 


ABSCESS  FORMATION  WITHOUT  COMPLICATIONS    401 

Case  XXXI  (Forssell). — A  large  incision  was  made  on 
the  middle  of  the  forearm  down  to  the  palm,  cutting  the 
anterior  annular  ligament  and  part  of  the  palmar  aponeurosis, 
a  large  abscess  was  found  in  the  palm  and  under  the  annular 
ligament  and  in  the  forearm  lying  between  the  ulnar  muscles 
and  the  flexor  profundus  digitorum.  The  tendon  sheaths 
were  entirely  intact. 

Case  XXXII  (Forssell). — About  a  week  after  the  primary 
injury  there  was  an  increase  of  pain  in  the  arm,  which  becarrie 
red,  sensitive,  and  swollen.  After  four  or  five  days  pus  was 
forced  out  by  pressure  on  the  forearm,  a  7  cm.  cut  was  made 
above  the  wrist  through  the  skin  followed  by  a  blunt  dissec- 
tion to  the  tendon  sheaths,  from  which  thin  pus  was  evacuted ; 
a  drain  was  inserted  through  this  opening  under  the  annular 
ligament  out  through  the  hand.  On  the  ulnar  side  of  the 
forearm  an  incision  was  made,  15  cm.  long,  carried  down 
between  the  flexor  profundus  digitorum  and  the  flexor  carpi 
ulnaris ;  pus  was  met  with  here  and  the  tendons  of  the  flexor 
profundus  digitorum  were  surrounded  with  pus  in  the  lower 
three-fourths  of  the  forearm. 

Case  XXXIII  (Tomier). — Two  weeks  after  injury  it  was 
noticed  that  the  entire  arm  was  swollen,  especially  the  fore- 
arm. On  the  same  day  the  ulnar  bursa  was  opened,  a  large 
amount  of  pus  was  found,  much  burrowing  behind  the  muscles 
of  the  forearm,  and  wide  incisions  were  made  here. 

Case  XXXIV  (Forssell)  .—The  lower  third  of  the  fore- 
arm was  swollen  and  tender,  but  the  patient  had  no  spon- 
taneous pain.  The  ulnar  bursa  was  opened  throughout  its 
length  and  the  incision  continued  over  the  lower  third  of  the 
forearm.  This  exposed  an  abscess  lying  on  the  interosseous 
membrane  under  the  muscles.  Counter-incisions  were  made. 
Culture  showed  streptococcus. 

Case  XXXV  (Tomier). — Incision  was  made  into  the 
radial  bursa  and  on  the  forearm  extending  on  the  radial  side, 
exposing  ^an  abscess  lying  between  the  pronator  radii  teres 
and  the  'flexor  carpi  radialis,.  behind  the  deep  flexors. 

Case  XXXVI  (Tomier). — Both  bursse  opened,  anterior 
annular  ligament  incised,  large  amount  of  thick  yellowish- 
green  pus  was  found  in  the  lower  part  along  the  interosseous 
membrane. 


26 


402 


FOREARM  INVOLVEMENT 


Every  case  that  has  come  under  my  observation 
has  borne  out  these  deductions  and  from  these  reports 
and  my  studies  it  is  certainly  justifiable  to  outline  the 
position  of  these  secondary  abscesses  as  we  have.  The 
position  of  the  pus  at  a  point  one  and  one-half  inches  up 
on  the  forearm  is  shown  in  cross-section  (Fig.  130),  and 
also  the  position  of  the  pus  when  it  reaches  the  middle  of 
the  arm  is  shown  in  a  second  cross-section  (Fig.  131). 


Palmar  IS   long. 
Flexor  prof.  dig. 
Ubiar  a. 


Pronator 

quadrat 

Ulna  -  '\^ 

Interosieous  mar. 
Extensor  carpi  ulnar i^ 

Extensor  min.  dig 


ublimis  dig. 
'ian  n. 
Flexor  carpi  radiolij 
■Flexor  long,  poll icii 

Radial  a. 

Space  held 
open 

Supinator  long. 

Ext.  carpi 
radialis  lonor 

Ext.  carpi 
radialis  brevi- 

-Jiadius 


-  i:,xtensor  prjrni 
irL'ernodii  poUicu 

^rtensor  ^yecundt 
.nternodii  poinds    • 

Extensor  com.   di^. 


Fig.  130. — Drawing  of  cross-section,  7  cm.  above  the  radial  styloid.    Open  space 
designates  outline  of  pus  pocket  as  ordinarily  seen. 


Symptoms,  Signs,  and  Diagnosis. — The  diagnosis 
of  a  forearm  involvement  is  based  on  the  knowledge  of 
an  associated  tendon-sheath  infection  of  the  ulnar  or 
radial  bursae  or  a  middle  palmar  infection  and  the  signs 
incident  to  the  development  of  any  deep  abscess.  Especi- 
ally in  an  ulnar  bursitis  which  has  existed  two  or  more 
days  before  drainage  do  we  look  for  a  beginning  forearm 
involvement.  In  any  case,  we  have  the  development  of 
increased  swelling  of  the  forearm.  The  swollen  part  has 
not  the  soft  feeling  incident  to  edema,  but  a  full,  tense 


ABSCESS  FORMATION  WITHOUT  COMPLICATIONS   403 

feeling  as  if  the  forearm  were  an  overdistended  bag. 
There  may  be  but  Httle  increase  in  redness.  The  indura- 
tion seen  in  subcutaneous  abscesses  will  be  absent. 
However,  tenderness  to  deep  pressure  is  increased.  The 
wrist  becomes  more  or  less  fixed,  and  the  careful  observer 
has  no  difficulty  in  suggesting  the  diagnosis  on  the  his- 
tory of  these  findings.  Of  course,  later,  when  the  pus 
had  infiltrated  every  part,  even  the  novice  can  make 
the  diagnosis.  Early  diagnosis  is  greatly  to  be  desired, 
however.     It   should   be    urged    that   in   case   of   doubt 


"^  " '  nK~9-.^^HBk  S^  \-ni  £  %i^, 

H| 

1 

^BLI^::^ 

*                    '"5*  W 

\=, 

Fig.   131. — Photograph  of  forearm  just  below  the  middle,  showing  position  of 
pus  (white  area)  in  its  relation  to  the  ulnar  artery  and  the  median  nerve. 


incision  may  be  made  after  the  manner  already  suggested, 
by  lateral  incisions,  without  in  any  way  jeopardizing  the 
patient's  forearm.  Whenever  I  open  an  ulnar  or  radial 
bursa,  and  there  is  any  question  in  my  mind  as  to  forearm 
involvement,  the  forearm  incisions  are  made.  Indeed, 
these  same  incisions  may  be  used  to  drain  the  upper  end 
of  the  sheaths  in  the  forearm.  So  that  the  incisions  thus 
serve  two  purposes:  they  drain  the  bursae,  and  if  pus  is 
already  in  the  forearm  or  develops  subsequently,  they 
afford  it  an  immediate  outlet. 


404  FOREARM  INVOLVEMENT 

Deep  Forearm  Involvement  Associated  with  Wrist-joint  Invasion. 

If  operated  upon  early  the  involvement  of  the  wrist- 
joint  will  be  uncommon.  In  certain  cases,  however,  it 
will  be  met  with  either  early  in  the  course  or  later  as  a 
complication.  The  wrist-joint  involvement  is  a  most 
serious  complication,  and  it  should  be  watched  for, 
particularly  in  aged  patients  with  involvement  of  the 
radial  bursa  (tendon  sheath  of  the  flexor  longus  pollicis). 
By  reference  to  the  cases  it  will  be  seen  that  of  the  8  cases 
here  reported,  7  were  fifty-four  years  of  age  or  older.  It  is 
to  be  noted  particularly,  however,  that  every  case  was 
one  of  involvement  of  the  radial  bursa,  either  alone  or  in 
conjunction  with  other  foci.  In  5,  the  primary  process 
was  in  the  thumb.  One  cannot  help  but  feel  that  this  is 
more  than  a  coincidence;  as  yet,  however,  no  definite 
anatomical  reason  can  be  adduced  to  explain  it.  In  none 
of  my  injections  of  this  synovial  sheath  has  the  mass 
ruptured  or  extended  into  the  wrist-joint. 

Examination  of  the  Radial  Bursa  in  Cadavers. — 
To  determine  whether  or  not  there  is  at  times  a  normal 
opening  connecting  the  radial  bursa  and  the  wrist-joint, 
with  the  assistance  of  Prof.  P.  T.  Burns  and  Dr.  A.  T. 
Horn,  of  the  Anatomical  Department  of  the  North- 
western University'  Medical  College,  I  have  examined  30 
cadavers,  and  in  not  one  of  them  have  we  found  any 
normal  opening,  although  Prof.  Burns  states  that  he  has 
at  times  noted  such  a  communication.  This  is  borne  out 
by  other  observers,  but  it  must  be  extremely  rare. 
According  to  Schwartz,  the  parietal  layer  of  the  ulnar 
bursa  is  attached  to  the  ligaments  and  periosteum  of  the 
carpal  bones,  particularly  the  unciform  and  os  magnum. 
Forssell  states  that  in  cases  of  carpal  involvement  he  has 
noted  that  the  os  magnum  suffers  the  greatest  destruction 
(Fig.  132). 


INVOLVEMENT  WITH  WRIST-JOINT  INVASION     405 

Pathology  Found  in  Serious  Wrist-joint  Involve- 
ment.— Since  my  own  experience  with  this  condition 
is  rare,  I  have  been  compelled  to  turn  to  the  literature 
for  reports  of  postmortems.  Of  my  personal  cases,  5  in 
number,  all  recovered.  One  case  (Case  XLIX)  is  found 
in  the  chapter  dealing  with  Osteomyelitis.  Owing  to 
the  seriousness  of  this  complication,  one  may  be  pardoned 
for  making  rather  complete  reports. 


OSes 


(PMP5 


Fig.  132. — Drawing  showing  intimate  relation  of  the  ulnar  bursa  to  the  os 
magnum  and  its  early  involvement.  Notice  the  association  of  the  radial  bursa 
and  the  trapezium:  DSCS,  dorsal  subcutaneous  space;  IP  MPS,  infected  process 
leading  from  middle  palmar  space;  lUB,  infected  ulnar  bursa;  0,  ostium;  OM, 
OS  magnum;  RB,  radial  bursa;  S,  sinus;  UV  and  A,  ulnar  vein  and  artery. 

In  the  first  case  the  position  of  the  sinus  openings  on 
either  side  above  the  annular  ligament  at  the  site  of  the 
two  vessels  emphasizes  the  tendency  of  these  abscesses 
to  follow  the  vessels  (see  Experiment  47,  where  the  only 
place  the  mass  became  subcutaneous  was  on  the  ulnar 
side  just  above  the  annular  ligament).  The  absence  of 
tenderness  and  pain  about  the  necrotic  joint  is  also  worthy 


406  FOREARM  INVOLVEMENT 

of  note.     The  involvement  of  the  radio-ulnar  joint,  as 
here  noted,  \s  a  frequent  complication. 

Case  XXXVII  (Bauchet).— Deep  phlegmon  of  the  right 
thumb;  deep  phlegmon  of  the  hand ;  phlegmon  of  the  forearm ; 
fistulous  processes;  abundant  suppuration.  Great  scar  over 
the  sacrum;  septic  infection.     Death.     Postmortem. 

This  man,  between  fifty-five  and  sixty  years  old,  gives  a 
history  of  an  inflammation  of  the  thumb  two  months  before 
entrance.  On  the  forearm  there  are  two  openings;  one  is  at 
the  inside  and  the  other  at  the  outside  of  the  anterior  surface ; 
both  are  about  4  cm.  from  the  radio-carpal  joint.  These  two 
openings  are  longitudinal,  about  2  cm.  long,  with  edges 
grayish  and  fungous.  At  the  level  of  the  first  phalanx  of  the 
thumb  one  sees  the  scar  of  a  former  purulent  focus.  No  red- 
ness; dorsal  aspect  of  the  hand  shows  no  tumefaction;  no 
sinuses.  Tenderness  to  pressure  is  not  very  acute;  the  wrist 
is  neither  swollen  nor  painful.  By  pressing  on  the  palm  of 
the  hand  or  on  the  lower  part  of  the  forearm,  one  causes  a 
notable  quantity  of  whitish,  poorly  mixed,  fluid  pus,  without 
a  bad  odor,  to  flow  out  through  the  openings  already  men- 
tioned. The  probe  introduced  through  these  openings  slides 
a  considerable  distance  along  the  lower  layers  of  the  forearm, 
but  meets  no  denuded  portions  of  the  bone. 

Aside  from  the  two  openings  already  mentioned,  one  notes 
still  farther  inward,  at  the  level  of  the  upper  third  of  the 
anterior  surface,  a  small  opening  from  which  pus  escapes, 
but  in  smaller  quantity  than  from  the  other  two  openings. 
By  pressing  the  ulna,  the  radius,  and  at  the  same  time  trying 
to  make  the  patient  move  the  wrist,  one  notes  a  grating 
between  the  ulna  and  the  radius  and  between  these  bones  and 
those  of  the  wrist,  which  resembles  nothing  more  than  two 
nuts  being  rubbed  together. 

Diagnosis. — Deep  whitlow  of  the  thumb;  extension  of 
inflammation  into  the  great  common  synovial  sheath  of  the 
tendon  of  the  little  finger;  rupture  of  the  focus  between  the 
muscular  layers  of  the  forearm,  but  more  especially  of  the 
deeper  part ;  extension  of  the  suppuration  to  the  carpal  joints ; 
necrosis  of  the  bones. 

Postmortem. — The  tendons  are  fixed  in  an  invariable  posi- 
tion, and  to  free  them  it  is  necessary  to  cut  out  the  resisting 
fibrous  adhesions.     These  changes  are  evident  in  the  palm 


INVOLVEMENT  WITH  WRIST-JOINT  INVASION      407 

of  tho  hand,  under  the  annular  ligament,  and  the  lower  part 
of  the  forearm,  all  along  the  synovial  sac.  These  changes 
extend  to  the  ends  of  the  tendons  of  the  thumb  and  little 
finger.  They  stop  slightly  above  the  metacarpo-phalangeal 
joints  of  the  index,  middle,  and  ring  fingers.  Along  these 
fingers  the  synovial  sheaths  and  the  tendons  are  absolutely 
intact.  The  large  focus,  black  and  purulent,  has  an  exit  in 
the  tu'o  openings  before  mentioned.  At  the  upper  and  outer 
part  it  is  closed,  and  the  muscles  of  the  forearm  on  this  side 
are  healthy.  On  the  ulnar  side,  on  the  contrary,  the  fibro- 
synovial  sac  is  frayed,  and  the  pus  has  spread  to  the  level  of 
the  upper  part  of  the  forearm,  between  the  deep  and  super- 
ficial muscular  layers.  This  purulent  focus,  formed  by  rup- 
ture of  the  synovial  sheath,  has  its  exit  in  the  smaller  opening, 
which  has  already  come  under  discussion. 

The  joints,  radio-carpal,  radio-ulnar,  and  carpal,  are  open 
anteriorly  and  communicate  extensively  with  the  palmar  pur- 
ulent focus,  through  several  openings.  The  bones  are  neither 
red  nor  spotted  nor  crumbling.  They  are  rather  of  an  ivory- 
gray  color  and,  in  spots,  blackish ;  there  is  no  false  membrane 
or  generative  abscess  in  the  joint;  but  the  cartilage  has  been 
destroyed,  almost  entirely  resorbed,  and  has  disappeared;  the 
bones  bared  of  this  cartilage  resemble  bones  which  have  been 
soaked  in  water  for  some  time. 

The  following  case,  reported  in  the  inaugural  disserta- 
tion of  Max  Tornier,  from  the  Griefswald  Clinic  (Prof. 
Helferich),  emphasizes  again  the  frequency  of  sinus 
openings  in  carpal  involvement  at  the  sites  we  have 
mentioned. 

Case  XXXVIII. — Phlegmon  of  the  forearm,  involvement 
of  carpal,  and  radio-carpal  joints. 

Man,  ,aged  fifty-eight  years.  On  the  ulnar  side  of  the  wrist 
there  is  a  sinus  opening  4  cm.  long,  through  which  a  probe 
reaches  down  into  the  wrist-joint.  Under  narcosis  and  anemia 
Langenbeck's  incision,  the  tendon  of  the  long  radial  muscle, 
infiltrated  with  pus,  was  resected  for  about  8  cm.  Resection 
of  the  proximal  line  of  the  carpal  bones,  between  which  small 
masses  of  pus  were  found.  Drainage  established.  Very 
dilatory   course;   the   distal   row   of   carpal    bones   sloughed 


408  FOREARM  INVOLVEMENT 

through  necrosis.  An  erysipelas  with  numerous  abscesses  on 
the  forearm  made  further  incisions  necessary.  When  dis- 
missed the  incisions  were  healed ;  the  wrist  hung  loose. 

The  following  cavSe  from  the  same  report  shows  the 
beneficial  results  of  early  and  radical  operation  in  the 
case  of  wrist-joint  involvement,  and  shows  the  inade- 
quacy of  superficial  incisions  on  the  forearm. 

Case  XXXIX. — Severe  phlegmon  of  the  hand  and  fore- 
arm; caries  of  carpal  and  radio-carpal  joints. 

Patient,  aged  sixty-three  years.  Two  weeks  after  infection, 
incision  over  abscess  on  flexor  and  extensor  sides  of  forearm. 
Two  weeks  later,  second  incision  through  the  intermuscular 
spaces  to  the  ligamentum  interosseum.  Iodoform  drainage. 
No  fever  in  evenings. 

The  probe  in  the  wound  of  the  dorsal  incision  strikes  carious 
bones  of  the  wrist ;  it  is  pushed  on  in  the  direction  of  the  dorso- 
radial  incision  to  the  wrist-joint.  The  latter  is  opened,  and 
shows  destruction  of  the  cartilage  and  the  bone.  The  joint 
is  filled  with  pus.  Resection  of  the  navicular,  semilunar, 
trapezium,  and  trapezoid.  Good  healing  under  Langenbeck's 
extension  bandage.  Good  granulation.  Daily  massage. 
Patient  dismissed  for  a  few  days  and  did  not  return. 

Besides  demonstrating  the  pathology  of  severe  case.^ 
of  carpal  involvement  and  the  extension  of  infection 
to  this  and  the  forearm,  from  the  tendon  sheaths,  Case 
XL  emphasizes  the  error  that  often  occurs  in  mistaking 
for  pus  the  enormous  edema  w^hich  is  found  upon  the 
dorsum  in  these  cases  of  palmar  infections. 

Case  XL  (Forssell). — Suppuration  of  the  radial  and  ulnar 
bursse  with  involvement  of  the  radio-ulnar  radio-carpal,  and 
carpal  joints  and  forearm. 

J.  L.,  aged  fifty-four  years.  Woman.  Pain  in  the  left  hand 
from  no  known  reason;  three  days  later  visited  hospital. 
Seven  days  later,  left  hand  (except  for  thumb  and  second  and 
third  phalanges  of  the  other  fingers)  and  to  a  certain  extent 
the  whole  arm  were  swollen;  pain  over  the  whole  back  of 
hand,  more  in  the  palm,  especially  in  the  fourth  interosseous 


INVOLVEMENT  WITH  WRIST-JOINT  INVASION     409 

space.  Finger  half-bent;  extension  very  painful.  Tempera- 
ture, 100.5°.  Incision  of  the  dorsum  on  the  same  clay;  little 
pus.  Incision  along  the  tendon  sheaths  of  the  first  and  fifth 
fingers;  communication  established  between  this  and  incision 
above  the  ligament.  Also  incision  over  the  flexor  carpi 
ulnaris,  with  communication  with  the  last-mentioned  incision. 
Pus  in  large  quantities  from  all  the  incisions. 

Four  weeks  after  onset  of  infection  the  tendons  removed 
so  far  as  they  appeared  infected.  All  carpal  bones  removed 
with  a  curette  except  the  trapezium  and  the  upper  part  of  the 
third  metacarpal  bone. 

Discharged  after  three  months  with  ankylosis  of  the  joint 
of  the  hand. 

Case  XLI  (Forssell). — ^Tenosynovitis  of  radial  and  ulnar 
uursae,  with  involvement  of  the  carpus. 

G.  K.,  aged  sixty  years,  January  7,  1898.  After  a  small 
wound  at  the  end  of  the  thumb,  symptoms  of  tenosynovitis 
in  the  thumb  and  little  finger.  Same  day,  incision  in  the 
tendon  sheath  of  the  thumb. 

January  8.  The  ulnar  bursa  was  completely  cleft;  incision 
into  the  upper  part  of  the  radial  bursa. 

Aside  from  an  insignificant  necrosis  of  the  thumb  and  little 
finger  tendons,  all  went  well  until  January  16,  when  symp- 
toms of  an  infection  of  the  wrist  arose.  These  increased,  and 
(January  18)  necessitated  an  incision  into  the  wrist- joint,  a 
considerable  serofibrinous  secretion  being  found.  Joint 
washed  out  with  i  per  cent,  sublimate  solution.  Gradually 
distinct  formation  of  pus  took  place,  which  led  to  a  partial 
resection  of  the  wrist  (February  5). 

In  the  following  case  the  decreased  sensitiveness  in  the 
area  of  the  distribution  of  the  median  nerve  serves  to 
emphasize  the  tendency  of  infection  to  spread  along  that 
nerve,  as.  demonstrated  in  Experiment  47  and  shown  in 
Fig.  131^ 

Case  XLI  I  (Forssell). — Tenosynovitis  of  the  thumb,  little 
finger,  and  ulnar  bursae.  Phlegmon  of  the  forearm  and 
articulation  between  hand  and  forearm. 

S.  T.,  aged  thirty-three  years,  female.  April  4,  1898. 
Distinct   symptoms   of   suppuration   of   the    carpal    tendon 


410  POREARM  INVOLVEMENT 

sheaths  (tendon  sheath  of  the  little  finger  intact)  and  on  the 
forearm.  Only  sHght  pain  on  passive  movements  of  the 
finger;  "the  finger  twinges;"  the  same  is  true  of  palpation 
of  the  palm  and  the  flexor  side  of  the  forearm.  Complete 
opening  of  the  ulnar  bursa;  by  mistake  the  sheath  of  the  little 
finger  was  opened;  no  pus;  incision  into  the  thumb;  pus 
within  and  without  the  sheath. 

April  II.  Incision  into  the  lower  part  of  the  forearm 
down  to  the  ulna  (burrowing  of  pus).  For  three  days  there 
have  been  symptoms  of  infection  of  the  wrist-joint ;  pus  pours 
from  a  small  hole  in  the  capsule  between  the  pisiform  and 
cuneiform.  Around  the  tendon  of  the  flexor  longus  pollicis 
there  is  much  pus,  wherefore  an  incision  of  the  same  is  made ; 
it  was  especially  necrotic  in  the  region  of  the  carpal  ligament; 
here  there  is  also  necrosis  of  other  tendons. 

April  12.  Much  pus  in  the  wrist  and  upper  arm.  Several 
carpal  bones  removed  under  anesthetic. 

April  i6.  Temperature,  102°  to  105°.  Amputation  of 
the  arm.  Examination  of  the  amputated  arm;  elbow-joint 
intact;  all  pus  cavities  opened  except  the  suppurated  tendon 
sheaths  of  the  fourth  and  third  fingers.  Necrosis  of  all  ten- 
dons at  the  anterior  annular  ligament;  the  condition  of  the 
median  nerve  was  by  mistake  not  investigated. 

April  17.     Exitus  12  M. 

Epicrisis. —V^orthy  of  notice  was  the  decreased  sensitive- 
ness and  pain  in  the  median  region,  due  probably  to  the  com- 
pression of  the  nerve.  The  inflammation  of  the  wrist  was 
possibly  due  to  the  infection  of  the  joint  between  the  pisiform 
and  the  cuneiform ;  in  the  capsule  of  this  joint  a  certain  defect 
was  noted,  whether  primary  or  secondary,  still  pointing  to  a 
certain  weakness  in  the  boundary  of  the  canal  toward  the 
carpal  canal. 

In  the  subjoined  case  the  wrist  did  not  become  involved 
until  fifteen  days  after  the  beginning  of  the  infection.  In 
this  case,  as  in  many  of  the  others  reported  here,  there 
may  be  some  question  as  to  whether  or  not  the  incisions 
were  made  early  enough  and  at  the  proper  sites. 
Throughout  the  literature  it  is  evident  that  surgeons 
have  paid  too  little  attention  to  the  fascial  pockets  in 
which  pus  lies,  confining  their  attention  almost  entirely 
to  the  tendon  sheaths. 


INVOLVEMENT  WITH  WRIST-JOINT  INVASION     411 

Case  XLIII. — Compouml  dislocation  of  tluinil).  Infec- 
tion of  radial  and  ulnar  bursa?,  resection  of  necrotic  carpal 
bones. 

C.  E.,  aged  fifty-eight  years.  A  large  quantity  of  grayish- 
yellow,  thinly  fluid  pus  was  freed  by  opening  the  radial  bursa. 
An  incision  which  liad  been  made  on  the  volar  side  of  the 
thumb  lengthened,  and  the  tendon  cut  out. 

May  20.  Complete  splitting  of  the  ulnar  bursa  and  the 
tendon  sheath  of  the  little  finger;  in  the  bursa  and  the  tendon 
sheath  a  yellowish  fluid  pus.  No  burrowing  toward  the  fore- 
arm could  be  discovered.  The  swelling  on  the  hand  went 
down.  On  May  24  it  is  especially  noted  that  there  is  no 
swelling  around  the  wrist-joint.  The  superficial  tendons  of 
the  little  finger  had  become  necrotic  just  below  the  carpal 
ligament,  and  those  of  the  fourth  finger  as  well  showed 
beginning  of  necrosis  here. 

May  29.  Temperature,  37.3°  to  37.4°.  Slight  pain  in  the 
hand  near  the  wound  in  the  carpal  region.  Several  tendons 
showed  signs  of  necrosis.  On  the  anterior  side  of  the  wrist, 
exposed  bone  (radius,  carpal  bone?)  can  be  felt. 

June  7.  Temperature,  37.4°  to  38.2°.  Partial  resection 
of  the  wrist-joint.  Removal  of  the  carpal  bones  except  the 
trapezium  and  pisiform;  unciform  necrotic. 

By  these  cases  I  have  attempted  to  portray  the  pathol- 
ogy, symptomatology,  and  course  of  these  forearm  cases, 
complicated  by  wrist-joint  involvement.  The  diagnosis 
of  its  occurrence  depends  upon  the  crepitation  noted  in  the 
joint,  associated  with  an  increase  of  tenderness  and 
swelling  about  the  joint.  It  will  be  remembered  that  the 
original  infection  is  upon  the  flexor  surface.  The  sw^elling 
and  tenderness  are  here.  When  the  joint  becomes 
involved  the  dorsum  also  partakes  of  this.  Under  normal 
conditions  a  depression  is  noted  on  the  back  of  the  wTist- 
joint  to  the  radial  side  of  the  extensor  communis  tendons 
at  the  lower  end  of  the  radius.  This  marks  the  site  of 
the  radio-carpal  articulation.  When  this  fills  with  fluid 
the  depression  is  replaced  by  a  fluctuating  swelling, 
and  in  case  of  doubt  a  needle  can  be  inserted  here  and  the 
contents  of  the  joint  aspirated  for  diagnostic  purposes. 


412  FOREARM  INVOLVEMENT 

This  site  is  particularly  indicated  in  doubtful  cases,  since 
the  original  infection  being  upon  the  palmar  side,  there  is 
no  great  danger  of  infecting  the  joint  if  it  is  not  already 
involved. 

Forearm  Involvement  with  Secondary  Hemorrhage. 

One  of  the  most  serious  complications  met  with  in  the 
later  stages  of  forearm  involvement  is  that  of  hemor- 
rhage. The  onset  of  a  sudden,  profuse  hemorrhage  in  a 
patient  who  is  unable  to  care  for  himself  in  the  temporary 
absence  of  attendants  may  lead  to  an  immediate  lethal 
issue.  The  condition  is  especially  dreaded,  since  the 
surgeon  looks  upon  the  condition  as  most  difficult  to 
handle,  and  he  fears  to  undertake  the  dissection  which  he 
believes  to  be  necessary  to  find  the  point  of  hemorrhage 
and  ligate.  He  therefore  temporizes  with  a  bandaging 
of  the  arm  and  tamponade,  only  to  be  subjected  to  greater 
anxiety  on  account  of  a  subsequent  hemorrhage.  It 
would  seem  that  this  complication  may  be  successfully 
dealt  with  if  the  surgeon  will  only  haye  in  mind  the 
following  facts: 

1.  The  vessel  nearly  always  at  fault  is  the  ulnar. 

2.  The  surgeon  should  not  temporize,  but  cut  down 
upon  and  ligate  at  once  the  bleeding  vessel. 

The  reason  for  the  involvement  of  the  ulnar  vessel  is 
seen  by  examining  the  cross-sections  (Figs.  6i  to  65,  and 
131),  in  which  it  is  shown  that  the  pus  early  involves  this 
vessel.  The  line  of  extension  is  along  this  vessel,  both 
up  toward  the  elbow  and  downward  to  the  ulnar  side  of 
the  forearm.  The  radial  is  well  separated  from  the  space 
in  a  majority  of  cases. 

My  statements  do  not  depend  alone  upon  my  anatomical 
and  experimental  studies.  Clinical  proof  in  support  of 
it  can  be  adduced  from  my  experience,  and  also  from 
numerous  cases  reported  in  the  literature.  I  will  let  two 
cases  suffice  for  that:  one  that  came  under  my  observation, 


FOREARM  INVOLVEMENT  WITH  HEMORRHAGE     413 

and  one  from  the  service  of  Prof.  Velpeau  in  which  a 
postniorleni  was  performed.  This  latter  is  added  for  the 
further  reason  that  the  postmortem  serves  to  give  further 
corroboration  to  my^statements  as  to  the  position  of  pus 
in  these  cases,  a  fact  which  cannot  be  definitely  proved  ex- 
cept by  postmortem.    My  own  case  I  shall  report  briefly. 

Case  XLIV.— Mr.  H.  Referred  to  Dr.  Richter  at  the 
Post-Graduate  Hospital,  with  whom  I  saw  the  patient  in 
consultation. 

Ten  days  previous  to  the  onset  of  the  first  hemorrhage  the 
patient  had  suffered  from  a  tendon-sheath  infection  of  the 
ulnar  and  radial  bursae,  with  extension  into  the  forearm.  The 
infection  had  not  been  opened  promptly,  and  even  after  the 
primary  incisions  the  drainage  from  the  forearm  had  not 
been  satisfactory.  Dr.  Richter  had  made  free  drainage,  but 
by  that  time  the  vitality  of  the  vessel  had  been  impaired.  A 
sudden  profuse  hemorrhage  occurred,  which  jeopardized  the 
patient's  life  before  it  was  discovered  by  the  nurse.  A  con- 
strictor about  the  arm  and  tamponade  completely  controlled 
the  hemorrhage,  and  it  was  felt  that  it  would  not  recur. 
However,  two  days  later  a  second  profuse  hemorrhage 
occurred,  and  the  ulnar  vessel  was  cut  down  upon  as  soon  as 
the  patient  had  recovered  from  the  severe  shock.  The  source 
was  found  to  be  the  ulnar,  as  had  been  prognosticated.  It 
was  ligated  with  catgut,  and  the  patient  made  an  uneventful 
recovery.     Function  in  the  hand,  however,  was  impaired. 

The  history  of  the  following  case,  made  the  more 
interesting  by  the  personal  attention  of  the  eminent 
Prof.  Velpeau,  serves  further  to  emphasize  the  possibility 
of  hemorrhage  from  ulceration  of  the  ulnar  vessel.  The 
presence  of  the  fistulous  tracts  near  the  annular  ligament 
suggested^  the  necrosis  of  the  carpal  bones  which  was 
present,  and  the  deep  position  of  the  pus  in  the  forearm  is 
worthy  of  note.  The  whole  clinical  picture  was  one  of 
extensive  involvement  of  the  wrist-joint,  deep  phlegmon 
of  the  arm,  and  the  infection  of  synovial  sheaths  which 
at  a  later  day  would  in  all  probability  have  been  relieved 
by  operative  procedure. 


414  FOREARM  INVOLVEMENT 

Case  XLV  (Bauchet). — Whitlow  of  the  left  thumb  caused 
by  a  prick  of  a  needle;  multiple  abscesses  produced  by  the 
spread  along  the  synovial  sheath  to  the  wrist  and  forearm. 
Hospital  gangrene  complicating  the  abscesses  of  the  wrist 
and  following  the  tissues  along  the  ulnar  artery,  severe  hem- 
orrhage, tamponade,  tourniquet;  gangrene  of  hand  and  fore- 
arm; amputation;  danger  of  hospital  gangrene  in  stump. 
Recovery. 

Patient,  aged  fifty  years,  in  the  service  of  M.  Velpeau, 
Charity  Hospital;  sick  for  two  and  one-half  months;  entered 
April  25,  1851 ;  was  dismissed  August  13. 

About  two  and  one-half  months  ago  the  patient  pricked 
the  thumb  of  his  left  hand  with  a  needle.  There  resulted  a 
phlegmon  of  this  finger  which  extended  rapidly  over  the 
whole  hand;  abscesses  formed  on  the  palmar  aspect  of  the 
finger  and  hand,  some  of  which  opened  simultaneously  and 
some  of  which  were  opened  by  a  bistoury;  the  swelling  per- 
sisted, and  even  spread  through  the  entire  thickness  of  the 
wrist  and  forearm,  along  the  synovial  sheath. 

On  the  palmar  face  of  the  wrist  one  notes  several  sinus 
openings  from  which  passes  a  purulent  fluid,  \'iscid,  clear, 
and  thready;  by  pressing  the  palmar  surface  from  below  up- 
ward, one  causes  this  liquid  to  flow  back.  These  openings 
seem  to  communicate  freely  with  the  synovial  sheaths  of  the 
flexor  tendons  of  the  fingers  at  the  level  of  the  WTist. 

The  inflammation  spreading  from  the  hand  to  the  forearm 
along  these  channels  is  very  intense,  and  presents  the  char- 
acteristics of  a  diffuse  phlegmon.  During  the  next  seven 
weeks  the  patient  was  treated  in  an  expectant  manner. 

June  20.  Appearance  of  hospital  gangrene.  The  open- 
ings on  the  palmar  aspect  of  the  wrist  are  larger,  puffed  up, 
mushroom-like,  and  forming  a  large  projection  showing  a 
spongy,  fungous,  grayish  aspect. 

June  28.  Growth  of  the  wound,  which  now  co\ers  the 
whole  palmar  face  of  the  wrist.  Sinking  of  the  mushroom-like 
elevation  of  flesh.  All  the  tissues  between  the  skin  and  the 
bones  of  the  wrist  are  in  a  state  of  putrilage,  and  the  flexor 
tendons  are  floating  in  this  decomposed  matter.  These 
tendons  are  stripped  of  their  sheath,  exfoliated,  and  have 
lost  their  silvery  appearance. 

June  29.  During  the  preceding  night  considerable  hemor- 
rhage from  the  ulnar  artery. 

After  several  days  hospital  gangrene  developed  in  the  hand, 


FOREARM  INVOLVEMENT  WITH  HEMORRHAGE    41o 

and  Prof.  Velpeaii  amputated  at  the  upper  third  of  the  fore- 
arm.   The  patient  then  made  a  rapid  reco\ery. 

Pathological  anatomy  of  the  amputated  member.  A  care- 
ful dissection  permits  one  to  ascertain  that  the  ulceration 
involves  only  the  ulnar  artery;  the  central  end  of  this  artery 
is  stopped  by  a  blood-clot.  The  radial  artery  in  the  gan- 
grenous portion  is  filled  with  fibrinous  clots. 

Upon  examining  the  other  tissues,  one  notes  at  the  level 
of  the  focus  of  the  palmar  abscess  purulent  trails  which  ascend 
the  length  of  the  forearm  in  the  tendinous  grooves,  and  the 
length  of  the  aponeurotic  sheaths  of  the  muscles  of  the  ante- 
rior aspect  of  the  forearm,  to  the  level  at  which  the.  forearm 
was  amputated.  One  notes,  moreover,  an  infiltration  of 
purulent  fluid  betw^een  these  grooves  and  these  aponeurotic 
sheaths.  The  connective  tissue  of  the  forearm  is  infiltrated 
like  lard.    The  tissues  of  the  hand  are  completely  sphacelated, 

dead,  and  black. 

Resume. 

Subcutaneous  abscesses  ordinarily  develop  on  the  back 
of  the  forearm  but  may  involve  the  subcutaneous  tissue 
proximal  to  and  above  the  anterior  annular  ligament. 
This  especially  accompanies  ulnar  bursitis. 

Deep  abscesses  of  the  forearm  are  practically  always 
found  upon  the  flexor  surface  and  almost  always  conie 
from  a  rupture  of  the  proximal  end  of  the  ulnar  or  radial 
bursae.  These  abscesses  practically  always  lie  underneath 
the  flexor  profundus  tendons  and  muscles  and  on  the 
pronator  quadratus  and  interosseous  septum.  The  diag- 
nosis is  made  upon  an  associated  tendon-sheath  infection 
with  an  increase  of  swelling  and  pain  in  the  forearm. 

The  wrist- joint  may  be  involved  particularly  in  aged 
patients  with  radial  bursitis.  It  is  evidenced  by  bony 
crepitus  due  to  destruction  of  the  bones,  particularly  the 
OS  magnum.  Secondary  hemorrhage  occurring  in  the  fore- 
arm follows  long-continued  suppuration  about  the  vessels, 
especially  the  ulnar  artery.  The  surgeon  should  not  tem- 
porize but  cut  down  and  ligate  the  bleeding  vessels. 


CHAPTER  XXVIII. 

TREATMENT  OF  INVOLVEMENT  OF  THE 

FOREARM  SECONDARY  TO  HAND 

INFECTIONS. 

•TREATMENT  OF  UNCOMPLICATED  CASES. 

The  treatment  of  the  subcutaneous  abscesses  secondary 
to  lymphangitis  has  been  discussed  in  Chapter  XXIII. 

In  dealing  with  the  deep  forearm  involvement,  two 
methods  may  be  used :  ( i )  The  older  procedures  by  which 
the  incision  which  opened  the  ulnar  bursa  may  be  con- 
tinued upward  into  the  forearm,  cutting  the  anterior 
annular  ligament  (see  p.  259  for  full  description  of  this 
method).  This  procedure,  however,  I  have  abandoned 
except  in  rare  cases.  (2)  Following  the  anatomical 
studies  described  in  previous  chapters,  I  have  used  lateral 
incisions  upon  either  side  above  the  wrist  (Fig.  133).  In 
most  cases  only  one  has  been  used,  that  upon  the  ulnar 
side.  By  referring  to  the  cross-sections  and  Figs.  134  to 
137,  the  site  of  these  incisions  may  be  seen.  I  begin  my 
incision  about  an  inch  above  the  styloid  process  of  the 
ulna  and  carry  it  upward  for  about  three  inches,  cutting 
down  to  the  ulna  on  a  level  with  its  volar  surface.  The 
attachment  of  the  deep  fascia  to  the  bone  is  separated 
and  then  the  finger  is  inserted  between  the  tendons  and 
the  pronator  quadratus.  A  free  opening  is  secured.  If 
it  is  deemed  wise  to  make  a  second  incision  upon  the  radial 
side,  an  artery  forceps  is  passed  across  from  the  ulnar 
side  (Fig.  134).  The  forceps  should  hug  the  radius 
closely,  and  when  the  point  impinges  upon  the  skin  of  the 
radial  side  an  incision  is  made  through  the  skin  for  a 
distance  of  a  couple  of  inches.     The  opening  is  enlarged  by 


TREATMENT  OF  UNCOMPLICATED  CASES 


417 


separating  the  fascial  attachment  with  the  fingers.  Any 
pockets  between  the  tendons  or  muscles  are  widely  opened 
by  the  palpating  finger. 


Fig.  133. — Lines  represent  the  various  incisions  made  for  drainage  of  the 
infected  tendon  sheaths  and  their  possible  extensions  into  the  forearm.  (See 
text  for  complete  description.) 

If  the  abscess  has  been  opened  late  and  the  pus  has 
infiltrated    the    forearm    extensively,    I    commonl}^    add 


Ulnar  art  -,     / 


^A'leoian  nerve 


inar  nerve. 


Fig.  134.v^Cross-section  7  cm.  above  radial  styloid.  Artery  forceps  inserted 
transversely  in  juxtaposition  to  ulna  and  radius  through  the  anterior  inter- 
osseous space,  showing  that  incision  can  be  made  here  and  not  injure  important 
vessels  and  nerves.     Notice  tissue  between  radial  artery  and  the  forceps. 


an  incision  at  a  second  site  higher  up,  about  the  middle 
of   the  forearm.     Here  one  will   see   by  examining  the 
cross-section   (Figs.    131   and   135)   the  pus  tends  to  lie 
27 


418 


INVOLVEMENT  OF  THE  FOREARM 


between  the  flexor  carpi  ulnaris  and  the  flexor  sublimis 
around  the  ulnar  artery  and  nerve.  Therefore  an  incision 
is  made  about  one  inch  from  the  ulna  on  the  flexor  sur- 


FiG.  135. — Cross-section  of  forearm  at  about  its  middle.  The  knife  is  seen 
to  make  an  incision  beyond  the  flexor  carpi  ulnaris  and  the  flexor  profundus, 
which  incision  should  be  made  for  pus  in  the  middle  of  the  forearm.  (See  Fig. 
136.)     Cotton  packed  in  the  opposing  surface  shows  the  position  of  pus. 

face  of  the  forearm,  attempting  to  strike  the  area  between 
these  two  muscular  bodies  (Figs.  135,  136,  and  137)- 
The  opening  is  separated  widely  by  the  forceps  and  fingers 


Fig.  136. — Photograph  showing  the  proper  incisions  for  draining  abscesses 

in  forearm. 


after  the  skin  incision  is  made.  Instead  of  this,  one  may 
cut  down  directly  upon  the  flexor  surface  of  the  ulna  and 
separate  the  fibrous  attachment  of  the  flexor  carpi  ulnaris 


TREATMENT  OF  UNCOMPLICATED  CASES  419 

from  this  bone,  and  in  this  manner  separate  the  muscle 
from  the  flexor  sublimis  and  profundus  and  thus  drain  the 
pockets. 


Fig.  137.— Photograph  of  a  hand  of  a  patient,  showing  proper  incisions  for 
opening  tendon-sheath  infections  of  the  thumb  and  little  finger,  with  ulnar  bursal 
extensions  of  pus  in  the  forearm.  This  patient  made  a  complete  recovery  with 
function  and  left  the  hospital  at  the  end  of  one  month.  Function  was  complete 
at  the  end  of  three  months. 


Fig.  138. — Photograph  of  baby  G.'s  hand  and  forearm  three  days  after  inci- 
sion was  made  for  the  drainage  of  an  ulnar  bursal  infection  with  extension  into 
the  forearm.     (See  Case  XLVI.) 


420  INVOLVEMENT  OF  THE  FOREARM 

These  are  all  the  incisions  that  in  my  experience  have 
been  necessary  to  produce  rapid  cure  in  these  cases.     One 


Fig.  139. — Result  three  months  after  (baby  G.),  showing  extension  and  flexion 
of  fingers.  Perfect  function  restored  except  for  two  distal  phalanges  of  the 
little  finger. 


Fig.  140. — Same  hand  showing  the  result  at  the  age  of  thirteen  years. 


TREATMENT  OF  WRIST- JOINT  INVOLVEMENT      421 

should  use  care  not  to  cut  through  any  muscular  body, 
since  drainage  will  be  unsatisfactory.  The  incisions 
should  be  free  and  may  be  kept  open  from  twenty-four 
to  forty-eight  hours  by  sheet-rubber  strips  or  vaseline- 
saturated  gauze.  Even  in  very  young  individuals  this 
treatment  is  most  satisfactory.  My  youngest  case  of 
ulnar  bursitis  and  forearm  involvement  was  in  a  child 
(Case  XLVI,  Figs.  138,  139  and  140),  whose  photographs 
I  here  present. 

Case  XLVI. — Wesley  Hospital.  The  child  was  three 
months  old  when  it  was  treated  and  six  months  old  when  the 
second  photographs  were  taken.  There  was  absolutely  no 
impairment  of  function  in  any  of  the  joints  or  muscles  except 
the  little  finger,  in  which  it  lost  the  power  of  flexion,  as  will 
be  seen  by  examining  the  photographs.  Owing  to  the  age 
of  the  patient  and  the  severity  of  the  infection,  the  life  of  the 
patient  was  despaired  of  by  the  family  physician.  The  child 
left  the  hospital  at  the  end  of  the  eighth  day  after  the  above- 
described  incision  had  been  made. 

TREATMENT  IN  CASES  WHERE  THE  WRIST-JOINT  IS  INVOLVED. 

Besides  the  incisions  suggested  above  for  drainage  of 
the  forearm,  special  considerations  must  be  borne  in  mind 
when  dealing  with  involvement  of  the  carpal,  carpo- 
metacarpal, or  carpo-radial  articulations.  Ow^ing  to  the 
frequently  associated  involvement  of  the  radial  bursa, 
this  will  generally  have  been  opened,  and  in  serious  cases 
the  necrotic  tendon  will  have  been  removed.  The  fact 
that  when  this  occurs  the  patient  is  generally  of  advanced 
age  will  emphasize  the  necessity  of  radical  treatment 
rather  than  temporizing  measures  which  might  be  justifi- 
able in  younger  individuals.  This  holds  true  not  alone 
for  the  resection  of  the  tendon,  but  also  as  regards 
removal  of  the  carpal  bones.  In  every  one  of  the  several 
cases  reported  above,  in  which  the  joint  became  involved, 
a  resection  of  some  or  all  of  the  carpal  bones  was  indicated. 
Even  in  younger  individuals,  unless  prompt  and  radical 


422  INVOLVEMENT  OF  THE  FOREARM 

incisions  are  made,  associated  with  careful  after-treatment, 
unfortunate  sequelae  are  likely  to  result.  That  it  does  not 
always  ensue  I  am  convinced  by  two  patients  who  came 
under  my  obser\^ation,  in  which  the  joint  made  a  recovery 
without  necrosis  of  the  bones,  but  here  prompt  drainage 
had  been  instituted.  However,  I  cannot  speak  with 
authority  upon  this  point,  since,  fortunately,  my  own 
experience  with  this  serious  sequela  has  been  limited.  In 
three  cases  it  became  necessary  to  remove  necrotic  bone, 
and  in  these  cases  a  complete  removal  of  all  carpal  bones 
was  found  advisable.  A  study  of  the  anatomy  suggests 
the  cause  of  the  tenacity  of  this  infection  and  the  rapidity 
with  which  it  involves  the  entire  joint.  We  note  that, 
as  described  by  Gray,^  while  there  are  four  separate 
synovial  sheaths,  yet  in  reality  the  joint  proper  has  only 
two,  and,  moreover,  these  two  are  so  intimately  associated 
that  the  least  erosive  action  on  the  part  of  an  infection 
lying  in  one  would  cause  an  extension  to  the  other. 
Moreover,  the  removal  of  any  of  the  more  important 
carpal  bones  in  the  radio-carpal  articulation  will  permit 
of  immediate  extension  in  the  synovial  spaces  about  the 
distal  bones,  as,  for  instance,  in  Case  XXX  we  read: 
"Resected  proximal  line  of  carpal  bones,  later  distal  row 

'  Although  all  the  authors  agree  in  describing  the  radio-carpal  synovial  sac 
as  isolated  from  the  carpal,  there  is  great  variation  in  the  description  of  the 
carpal  sacs.  Cunningham  and  Quain  follow  Allen  Thompson,  and,  in  addition 
to  the  radio-carpal  and  cuneiform-pisiform,  describe  one  sac  between  the  semi- 
lunar and  cuneiform  above  and  the  os  magnum  and  unciform  below,  another 
between  the  scaphoid  above  the  trapezium  and  trapezoid  below,  these  being 
separated  from  the  carpo-metacarpal  sac  below,  with  a  single  sac  between  the 
trapezium  and  thumb  metacarpal.  Gerrish  follows  Testut,  giving  the  same 
description  with  the  exception  that  he  divides  the  carpo-metacarpal  between 
the  middle  and  ring  metacarpals  into  two.  Joessel,  on  the  other  hand,  shows 
a  communication  between  the  carpal  and  the  metacarpo-carpal  on  the  radial 
side,  with  a  separate  sac  for  the  metacarpo-carpal  of  the  ring  and  little  finger 
metacarpals.  Gray  shows  a  general  communication  between  the  carpal  and 
metacarpo-carpal.  This  difference  of  opinion  simply  demonstrates  that  the 
communications  vary  in  different  individuals.  In  a  surgical  consideration 
we  should  expect  a  more  or  less  free  communication,  consequently  in  this  dis- 
cussion I  have  followed  Gray's  classification. 


TREATMENT  OF  WRIST-JOTNT  INVOLVEMENT      423 

of  caq^al  bones  slouched."  Conseciucntly,  in  those  cases 
where  the  infec  tion  is  confined  to  the  radio-carpal  articula- 
tion we  should  attempt  to  remove  the  carious  bone  by  the 
curette  and  give  perfect  drainage  to  the  joint,  with  the 
hope  of  preventing  extension  to  the  carpal  synovial  sac. 
The  probable  involvement  of  the  radio-ulnar  synovial  sac 
should  be  borne  in  mind,  since  it  seems  to  be  a  frequent 
complication.  The  intimate  relation  of  the  ulnar  sheath, 
as  already  pointed  out,  results  in  early  and  extensive 
involvement  of  the  os  magnum  (Fig.  132). 

While  these  deductions  theoretically  are  true  and  in 
certain  cases  will  be  found  applicable,  in  the  majority 
of  cases  it  will  be  found  upon  operation  that  it  will  be 
necessary  to  remove  all  of  the  bones  of  the  carpus.  The 
ultimate  results  following  this  procedure  are  much  better 
than  one  would  think. 

When  the  carpal  synovial  sheath  is  involved,  however, 
we  may  remove  any  of  the  carpal  bones  with  the  exception 
of  the  cuneiform,  semilunar,  or  scaphoid  without  danger 
of  causing  a  spread  to  the  radio-carpal  joint. 

The  infection  of  the  synovial  sheath  between  the 
pisiform  and  cuneiform  may  spread  to  the  carpal  articula- 
tion, as  in  Case  XLII.  In  relation  to  which  Forssell 
quotes  from  Henle  to  the  effect  that  anatomically  there  is 
frequently  a  communication  between  the  two  sheaths. 

In  no  case  of  involvement  of  the  wrist- joint,  in  which 
the  diagnosis  was  delayed  three  weeks,  did  the  patient 
escape  without  the  removal  of  some  of  the  bones  of  the 
joint.  In  other  words,  there  was  considerable  erosion  of 
the  bones  before  the  diagnosis  was  made.  We  are  urged, 
therefore,  to  watch  with  special  care  aged  patients  with 
involvement  of  the  radial  bursa  and  to  open  the  joint  at 
the  first  evidence  of  infection.  I  am  convinced,  however, 
that  this  complication  should  be  a  rare  one  in  those  cases 
submitted  to  early  and  radical  treatment  for  infections  of 
tendon  sheaths  and  soft  parts.     In  each  of  the  five  cases 


424  INVOLVEMENT  OF  THE  FOREARM 

coming  under  my  observation  the  sheath  had  not  been 
opened  until  long  after  the  infection  had  begun.  Early 
in  the  course  of  joint  involvement  free  incision  will  give 
great  possibility  of  a  cure  without  the  necessity  for 
resection.  But  should  the  indication  arise  for  curettage 
or  removal  of  the  carpal  bones,  it  should  be  done 
thoroughly  and  completely  along  the  lines  suggested 
above. 

TREATMENT  IN  CASES  OF  SECONDARY  HEMORRHAGE. 

As  has  already  been  hinted  in  dealing  with  this  subject, 
those  cases  showing  hemorrhage  should  not  be  temporized 
with.  As  soon  as  the  patient  has  recovered  from  the 
primary  shock  and  before  the  temporary  tamponade  and 
constriction  have  been  removed,  the  surgeon  should  make 
an  incision  over  the  ulnar  vessel.  To  do  this  an  incision 
should  be  made  about  the  middle  of  the  forearm  on  the 
ulnar  side,  as  described  above.  The  flexor  carpi  ulnaris 
is  then  drawn  to  the  ulnar  side  and  the  artery  searched  for 
(see  Fig.  133).  The  site  of  the  hemorrhage  should  be 
sought  and  the  vessel  doubly  ligated  proximally  and 
distally.  Tamponade  and  clotting  cannot  be  depended 
upon.  Further  hemorrhages  are  almost  sure  to  occur  and 
leave  the  patient  in  such  serious  condition  that  he  may  not 
survive  the  combined  hemorrhage  and  infection. 

R6sum6. 

Subcutaneous  abscesses  should  be  opened  by  free 
incision. 

Deep  abscesses  in  the  forearm  are  best  treated  by  mak- 
ing incisions  directly  down  upon  the  ulnar  an  inch  and  a 
half  up  on  the  forearm  cutting  the  fascial  attachments 
of  the  bone  and  freely  opening  up  the  interosseous  space 
with  the  finger  inserted  between  the  tendons  and  the 
pronator  quadratus.  Counter-drainage  may  be  made 
upon  the  radial  side  just  superficial  to  the  radius.     The 


INVOLVEMENT  OF  THE  FOREARM  425 

ulnar  incision  particularly  should  be  from  two  to  three 
inches  in  length.  In  complicated  cases  involving:  the 
whole  forearm  where  incision  has  been  long  delayed,  it 
may  be  necessary  to  make  an  incision  two-thirds  of  the 
way  up  on  the  forearm  on  the  ulnar  side  between  the 
flexor  carpi  ulnaris  and  the  flexor  profundis.  This  inci- 
sion, however,  will  seldom  be  required. 

When  the  wrist-joint  is  involved,  prompt  drainage  of  the 
tendon  sheaths  may  end  in  recovery;  but  when  treatment 
has  been  delayed,  it  may  be  necessary  to  remove  all  of  the 
carpal  bone. 

In  cases  of  secondary  hemorrhage  the  vessels  should  be 
ligated  as  soon  as  the  patient  has  recovered  from  the 
primary  shock. 


CHAPTER  XXIX. 
SEQUELS  OF  INFECTIONS  OF  THE  HAND. 

CHRONIC  PROCESSES,  OSTEOMYELITIS,  ARTHRITIS, 
CONTRACTURES  AND  ATROPHY. 

In  cases  showing  a  long-continued  suppuration,  we  ask 
ourselves  what  structures  are  involved  which  prolong  the 
trouble,  or  why  we  have  inefficient  drainage.  Frequently 
both  factors  are  at  work.  By  far  the  most  frequent  causes 
are  osteomyelitis,  arthritis,  and  necrosis  of  tendons. 

Areas  which  were  primarily  poorly  drained  cavities 
are  soon  complicated  by  one  of  these  factors.  Suppu- 
rative arthritis  seldom  exists  without  concomitant  osteo- 
myelitis. Such  cases  frequently  give  a  history  of  primary 
tenosynovitis,  followed  by  osteomyelitis,  ending  in 
arthritis. 

Involvement  of  the  wrist-joint  has  been  discussed  in  the 
previous  chapter. 

The  pathology  of  these  cases  naturally  varies  with 
the  tendency  of  the  tissues  to  react  to  the  particular 
germ  which  is  the  exciting  cause,  the  length  of  time 
the  process  has  existed,  and  the  structure  involved. 
Grossly  the  most  important  findings  are  the  sinuses, 
which  are  an  almost  constant  accompaniment  of  chronic 
disease.  Here  we  note  several  types,  and  while  there  is  a 
distinct  difference  between  them,  any  system  of  classifica- 
tion is  inadequate.  We  might  say  the  osseous  and 
connective-tissue  types,  or  the  acute,  subacute  and 
chronic.  While  the  pathology  presents  some  justification 
for  either  system,  yet  the  reactive  resistance  of  the 
individual  and  the  kind  of  germ  enter  into  the  subject 
as  varying  factors;  consequently  only  generalized  state- 
ments can  be  made. 


INVOLVEMENT  OF  THE  FINGER  PROPER  427 

The  chronic  osseous  type  ])reseiits  three  pictures, 
varying  with  the  bones  involved:  (i)  Those  cases  where 
the  terminal  phalanx  is  the  seat  of  osseous  destruction; 
(2)  where  the  finger  proper  is  involved;  (3)  where  the 
metacarpal  and  carpal  bones  are  involved. 

INVOLVEMENT   OF   THE   FINGER   PROPER. 

Those  cases  (first  group)  showing  chronic  processes 
in  the  terminal  phalanx  have  already  been  discussed 
in  the  chapter  on  Felons  (Chapter  II). 

The  second  group  of  cases  noted  in  the  chronic  osseous 
type  is  that  which  comprises  suppurative  processes  of  the 
proximal  and  middle  phalanges.  We  all  have  had  oppor- 
tunity to  observe  that  the  proximal  interphalangeal  joint 
particularly  may  become  involved  early,  either  primarily 
or  secondarily.  In  the  case  of  the  metacarpo-phalangeal 
joint,  however,  there  is  more  fibrous  tissue  intervening 
between  the  tendon  sheath  and  the  joint  and  the  adjoining 
bone;  therefore  the  sheath  erodes  through  at  some  less 
resistant  point,  as,  for  instance,  at  the  proximal  inter- 
phalangeal joint,  in  the  course  of  the  tendon  over  the 
proximal  phalanx,  or  at  its  proximal  end  in  the  palm  of  the 
hand.  Frequently  I  have  seen  a  sinus  lead  from  the 
proximal  end  of  the  sheath  of  a  tendon  through  the 
palmar  fascia,  and  the  metacarpo-phalangeal  joint  still 
remain  intact  (Fig.  130).  Again,  the  metacarpo-pha- 
langeal joint  is  likely  to  escape  in  cases  of  palmar  abscesses 
where  the  diaphysis  of  the  metacarpal  has  become 
involved,- or  even  when  the  process  has  been  so  severe  as 
to  extend  under  the  annular  ligament  and  invade  the 
carpal  articulation.  It  has  been  my  experience  in  these 
cases  that  the  distal  articulation  frequently  excapes  even 
in  long-continued  synovial  disease  and  extensive  osteo- 
myelitis. 

Ordinarily  chronic  suppuration  in  the  finger  is  a  result 


428  SEQUELM  OF  INFECTIONS  OF  THE  HAND 

of  either  a  sloughing  tendon  or  an  involvement  of  the 
proximal  interi)halangeal  joint,  and  the  pathological  con- 
dition noted  in  Fig.  142  is  fairly  typical.  The  constant 
irritating  discharge  coming  from  the  necrosing  bone, 
passing  through  the  connective  tissue  rich  in  lymphatics, 
produces  an  excessive  deposit  of  granulation  tissue,  build- 
ing up  a  small  volcano-like  structure,  from  which  oozes 
forth  a  constant  stream  of  pus,  and  through  which  winds 
a  tortuous  canal  leading  down  to  the  necrotic  bone. 
Where  bone  alone  is  involved,   I  have  seen  this  crater 


Fig.  141. — In  this  case  the  metacarpo-phalangeal  joint  was  intact,  although 
the  tendon  sheath  was  involved  and  a  sinus  had  opened  at  its  proximal  end 
through  the  palmar  fascia,  all  of  the  distal  and  part  of  the  middle  phalanx  had 
been  lost  and  the  proximal  interphalangeal  joint  was  extensively  destroyed. 

clearly  defined,  occupying  no  greater  extent  than  the 
length  of  one  phalanx  and  raised  above  the  surface  for  a 
distance  half  the  diameter  of  the  finger.  This  characteris- 
tic picture,  however,  is  seldom  seen,  owing  to  the  very 
frequent  involvement  of  the  tendon  or  the  joint  in  the 
same  process.  Here,  while  the  development  of  granula- 
tion tissue  is  still  excessive,  the  mouth  of  the  crater  is 
generally  much  wider,  owing  to  the  excessive  discharge 
from  the  tendon  sheath.  The  granulation  tissue  is  not  so 
circumscribed,  although  very  abundant.  Moreover,  the 
picture  loses  some  of  its  force,  owing  to  the  associated 


INVOLVEMENT  OF  THE  FINGER  PROPER 


429 


swelling  of  the  finger  along  the  tendon  sheath,  the  absence 
of  which  in  the  first  case  serves  to  accentuate  the  local 
tumor  formation.     Again,  if  the  sinus  be  upon  the  dorsum 


pp 

.^M^"'-.     --y-^nP 

■  ^x^^Siftk  'X'"''''A. 

,^^-. 

■^~^^~^~~"^                                     h 

""-'•-■Trfr^^-' 

Fig.  142. — Drawing  from  pathological  section,  showing  sinus  leading  down 
to  carious  bone.  An  associated  tenosynovitis  has  increased  the  extent  of  the 
granulation  tissue  and  destroyed  in  part  the  typical  volcano-like  picture  of  an 
uncomplicated  palmar  bone  sinus.  A,  ostium;  B,  intact  bone;  MP,  middle 
phalanx;  PP,  proximal  phalanx. 


Fig.  143. — Uncomplicated  bone  sinus  on  dorsum  of  phalanx.     • 

there  is  less  granulation  formation,  owing  both  to  the 
smaller  amount  of  connective  tissue  and  probably  also  to 
the  great  reduction  in  the  number  of  lymphatics  (Fig. 

143)- 


430  SEQUELM  OF  INFECTIONS  OF  THE  HAND 

It  is  not  necessary  to  go  into  the  minute  pathology  of 
osseous  necrosis,  since  that  process  is  well  known  and 
described  in  the  ordinary  text-ijooks.  However,  a  few 
details  peculiar  to  these  two  phalanges  should  be  men- 
tioned. We  so  often  see  three  processes  in  conjunction 
so  that  it  is  difficult  to  vsay  in  what  sequence  they  deve- 
loped— namely,  tenosynovitis,  arthritis  of  the  proximal 
interphalangeal  joint,  and  necrosis  of  the  middle  phalanx. 
The  cross-sections  here  presented  demonstrate  the  close 


Fig.  144. — Cross-section  through  the  joint,  showing  head  of  the  proximal 
phalanx.  Notice  the  large  amount  of  tissue  between  the  tendon  and  the  joint 
cavity  as  compared  to  Fig.  145. 

proximity  of  the  tendon  sheath  to  the  bone  and  joint 
respectively  (Figs.  144  and  145).  From  the  character  of 
the  tissue  it  would  seem  reasonable  to  assume  that  the 
joint  is  first  involved,  and  the  phalanx  sequentially.  In 
the  few  early  cases  that  I  have  been  able  to  observe  dis- 
criminatingly, the  joint  seemed  to  have  the  more  extensive 
involvement  of  the  two.  However,  if  that  be  true,  why 
does  the  middle  phalanx  suffer  so  much  more  than  the 
proximal  one,  a  fact  which  I  have  had  the  opportunity  to 
verify  frequently.     Is  it  that  the  point  of  invasion  is  the 


INVOLVEMENT  OF  THE  FINGER  PROPER  431 

epiphysis  of  the  middle  phalanx?  Does  the  fact  that  that 
phalanx  only  has  an  epiphysis  articulating  with  the  joint 
have  any  bearing  on  the  subject?  This  question  must  be 
left  for  further  study. 

Again,  destruction  of  the  epiphysis  is  frequently  noted, 
while  the  diaphysis  is  only  partly  involved  (Fig.  142). 
The  anatomical  relation  of  the  sheath  of  the  tendon  to  the 
joint  capsule  and  the.  epiphysis  may  help  to  explain  this, 
but  it  is  possible  that  the  vascular  nature  of  the  epiphyseal 
tissue  may  have  considerable  bearing,  since  the  involve- 


FiG.  145. — Cross-section  through  the  epiphysis  of  the  middle  phalanx.  Notice 
the  loose  mesh  and  the  small  amount  of  connective  tissue  between  the  tendon 
and  the  bone. 

ment  may  have  its  origin  through  the  blood  supply  rather 
than  by  direct  erosion.  That  isolated  destruction  of  a 
diaphysis  of  a  phalanx  may  occur  at  times  cannot  be 
questioned,  and  a  study  of  the  cross-sections  demonstrates 
how  easily  this  can  occur  if  the  tendon  sheath  be  eroded. 
What  we  most  often  find  upon  operation  in  these  cases 
is  a  suppurative  arthritis  with  extensive  destruction  of 
both  the  epiphysis  and  shaft  of  the  middle  phalanx,  while 
the  proximal  surface  of  the  joint,  that  is,  the  head  of  the 
proximal  phalanx,   may  be  only  slightly  or  not  at  all 


432  SEQUELjE  of  INFECTIONS  OF  THE  HAND 

eroded  (Fig.  146);  at  least,  the  articular  surface  is  still 
clear  and  shining,  with  possibly  one  or  two  minute  foci 
of  destruction.  Frequently  it  has  shown  a  larger  area  of 
necrosis  upon  the  shaft  just  at  the  point  where  the  liga- 
ments of  the  joint  are  attached.  Indeed,  at  times,  either 
upon  the  volar  or  dorsal  surface,  varying  with  the  site  of 
the  original  infection,  I  have  scooped  out  at  this  site  an 
area  the  size  of  a  small  pea,  the  articular  surface  appar- 
ently being  free,  while  the  epiphysis  of  the  middle  phalanx 
was  almost  entirely  destroyed. 


Fig.  146. — Drawing  from  a  pathological  specimen,  showing  destruction  of  the 
epiphysis  of  the  middle  phalanx,  with  pinhead-sized  areas  of  the  necrosis  on  the 
head  of  the  proximal  phalanx.     MP,  middle  phalanx;  PP,  proximal  phalanx. 

Treatment. — In  the  chronic  processes  involving  the 
finger  proper,  the  diagnosis  must  be  made  first  as  to  the 
structure  involved.  If  the  tendon  sheath,  it  must  be 
opened  throughout  its  extent  to  give  perfect  drainage. 
Frequently  it  will  be  necessary  to  remove  the  tendon  in 
these  chronic  cases.  The  possibility  of  localized  involve- 
ment must  always  be  borne  in  mind.  In  these  cases  a 
plastic  exudate  forms  and  prevents  extension  along  a 
sheath;  here  only  so  much  of  the  sheath  as  has  been 
involved  should  be  exposed.  If  the  joint  be  invaded, 
some  judgment  is  called  for,  since  in  the  very  earliest 
stages  it  may  recover  with  partial  restoration  of  function 
if  the  infection  is  a  mild  one,  the  joint  surfaces  not  des- 


INVOLVEMENT  OF  THE  FINGER  PROPER  433 

troyed,  and  other  structures  which  might  prolong  the 
suppuration  are  un involved.  In  a  great  majority  of  the 
cases,  however,  considerable  destruction  of  the  proximal 
phalanx  will  have  taken  place  when  the  case  comes  to 
operation,  and  the  question  arises  whether  an  amputation 
should  be  advised.  Certain  sociological  factors  come  into 
consideration.  If  the  patient  be  a  laboring  man,  with  a 
family  dependent  upon  him,  and  at  examination  we  find 
an  extensive  destruction  of  the  joint  with  a  tenosynovitis, 
amputation  offers  the  quickest  method  of  giving  a  service- 
able hand.  If,  however,  the  patient  desires  to  preserve 
the  finger,  in  a  majority  of  the  cases  one  can  be  assured 
that  the  finger  may  be  preserved,  but  that  it  will  be 
somewhat  shortened.  Exceptionally  the  finger  may  be 
preserved  with  considerable  function.  In  certain  cases 
it  becomes  imperative  to  make  the  attempt,  as,  for 
instance,  in  infections  of  the  thumb.  This  member  is  so 
valuable  that  some  sacrifice  is  justifiable  in  the  attempt 
to  preserve  it.  In  Case  XLVII,  quoted  below,  the  articu- 
lar surfaces  and  a  considerable  portion  of  the  shaft  of  the 
proximal  phalanx  were  removed.  There  was  no  involve- 
ment of  the  tendon  sheath.  A  fairly  serviceable  opposing 
member  was  thus  saved  to  the  hand. 

Case  XLVII. — Primary  paronychia  of  thumb,  secondary 
suppurative  arthritis  of  interphalangeal  joint,  resection, 
ultimate  recovery,  with  preservation  of  the  thumb. 

C.  H.,  treated  in  the  Northwestern  University  Medical 
School  Dispensary,  May,  1902.  Infection  began  on  the  thumb 
under  the  nail  at  the  side  and  developed  into  a  typical  "run 
around."  -When  he  applied  at  the  dispensary,  four  weeks 
after  the  beginning  of  the  infection,  a  chronic  suppurative 
arthritis  had  developed,  involving  the  interphalangeal  joint. 
Under  narcosis  the  epiphysis  of  the  distal  phalanx  and  about 
half  of  the  distal  portion  of  the  proximal  phalanx  were  found 
partially  destroyed.  All  this  involved  bone  was  removed 
with  a  curette,  the  nail  was  removed,  silkworm-gut  drain 
inserted,  hot  boric  dressings  applied.  The  tendon  sheath  of 
28 


434 


SEQUELS  OF  INFECTIONS  OF  THE  HAND 


the  flexor  longus  pollicus  was  not  involved.  The  patient 
returned  repeatedly  for  dressings,  and  after  four  weeks  all 
discharge  ceased.  The  patient  was  discharged  with  the 
thumb  shortened  half  an  inch,  with  ability  to  flex  the  distal 
phalanx  20  degrees,  complete  function  in  the  metacarpo- 
phalangeal joint.  There  was  little  strength  to  the  flexion  of 
the  distal  phalanx,  but  it  served  admirably  as  an  opposing 
member  when  using  the  fingers  (Fig.  147). 

The  procedure  when  the  proximal  interphalangeal 
joint  of  the  fingers  is  involved  is  as  follows:  Owing  to 
the  frequent  destruction  of  the  proximal  end  of  the  middle 
phalanx,  this  is  chosen  for  attack,  and  the  entire  epiphysis 


Fig.  147. — Photograph  showing  thumb  in  which  joint  has  been  resected.      Notice 
the  opposing  ability  of  the  member.     (Case  XLVII.) 

and  generally  about  half  of  the  shaft  is  removed.  If  the 
articular  surface  of  the  proximal  phalanx  is  intact,  it  is 
not  disturbed,  otherwise  this  may  be  removed  also,  my 
desire  being  in  the  first  place  to  remove  all  necrotic  bone, 
and  secondly,  to  separate  the  ends  of  the  bone  so  far  that 
only  a  fibrous  union  will  take  place,  thus  allowing  some 
motion  at  this  joint  if  the  tendon  is  intact.  Otherwise 
no  motion  can  be  promised.  These  fingers  are  dressed  in 
slight  flexion,  so  that  if  no  function  results  they  will  not  be 
in  the  way  and  will  still  be  of  some  use,  at  least  for  cosmetic 
purposes.  Active  and  passive  motions  daily  are  insisted 
upon.  In  some  cases  I  have  tried,  with  moderate  success, 
a  variety  of  extension  on  a  straight  splint.     The  proximal 


IXVOLVEMEXT  OF  THE  FINGER  PROPER  435 

end  is  fastened  at  the  wrist,  and  at  the  distal  end,  adhesive 
straps  are  fastened  to  the  end  of  the  splint  and  the  distal 
portion  of  the  finger,  so  that  the  ends  of  the  necrotic  bones 
are  separated.  The  details  of  this  mechanical  contrivance 
may  be  seen  by  examining  Figs.  148  and  149.  This  aids 
in  preser\'ing  the  functionating  joint,  although  it  is  some- 
what difficult  to  retain  in  position.  The  splint  should  be 
removed  each  da}'  and  active  and  passive  motion  used 
diligently.  Not  much  can  be  promised  in  the  way  of 
function  in  a  majority  of  cases.  That  in  exceptional 
cases  these  lingers  can  be  saved  with  a  moderate  amount 
of  function,  even  in  some  cases  of  combined  suppurative 
arthritis  and  tenosynovitis,  is  demonstrated  by  Case 
XLVIII. 

Case  XLVIII. — Limited  tenosynovitis  of  index  finger, 
arthritis  of  proximal  interphalangeal  joint,  osteomyelitis  of 
middle  phalanx,  resection  of  phalanx,  recovery,  with  preserva- 
tion of  the  finger  and  slight  motion  at  the  joint. 

Miss  C.  W.  Seen  in  consultation  with  Dr.  C.  E.  Boddiger. 
Infection  had  begun  in  the  index  finger  by  a  prick  of  a  needle 
while  sewing  two  weeks  previously,  and  the  soft  parts  had 
been  opened  over  the  middle  phalanx. 

Condition  upon  Examination. — Suppurative  tenosyno^•itis 
of  the  index  tendon  extending  to  the  metacarpo-phalangeal 
articulation,  but  no  farther.  Tendon  exposed.  Suppurative 
arthritis  of  the  proximal  interphalangeal  joint  with  destruction 
of  the  proximal  end  of  the  middle  phalanx.  Distal  phalanx 
not  involved,  articular  surface  slightly  clouded,  but  not 
eroded. 

Operation. — Tendon  sheath  opened  throughout  extent  of 
infected  area.  Middle  phalanx  resected  to  one-half  its  extent. 
Dorsal  counter-incision  made  at  side  for  thorough  drainage, 
and  hot  boric  dressings  applied. 

Course. — After  three  weeks  the  finger  had  entirely  healed; 
flexion  at  metacarpo-phalangeal  and  distal  phalangeal  joints 
perfect;  flexion  at  proximal  interphalangeal  joint  15  degrees. 
Six  months  after  operation  atrophy  of  soft  tissues  of  distal 
and  middle  phalanges.  The  patient  states  that  the  finger  is 
not  of  great  service,  but,  on  the  other  hand,  is  not  in  the  way, 
and  she  is  very  glad,  for  cosmetic  reasons,  that  it  was  saved. 


436 


SEQUELM  OF  INFECTIONS  OF  THE  HAND 


Where  there  is  only  a  destruction  of  the  synovial 
covering  of  the  joint,  resection  is  not  indicated.  A 
functionating  joint  can  be  restored  in  case  of  ankylosis  if 
the  tendon  sheath  is  not  involved,  as   I   have  had  the 


Fig.  148. 


Fig.  149. 


Figs.  148  and  149.  A  photograph  of  a  finger  with  a  chronic  suppurative 
arthritis  of  the  middle  metacarpo-phalangeal  joint,  dressed  in  extension  pro- 
duced by  an  ordinary  rubber  band  attached  to  the  end  of  the  finger  by  means 
of  a  string  tied  to  it  and  the  ends  fastened  through  the  eyes  of  a  button,  the 
latter  being  attached  to  the  finger  by  narrow  adhesive  strips  running  around 
the  finger  up  to  the  middle  metacarpo-phalangeal  joint — a  gauze  roller  around 
the  adhesive  strips.  Extension  is  secured  by  fastening  the  rubber  band  on  the 
back  by  a  piece  of  adhesive  plaster,  as  shown  in  Fig.  149.  The  board  splint  on 
the  palmar  surface  is  prevented  from  being  displaced  up  the  arm  or  laterally  by 
adhesive  strips  as  shown  in  the  figures.  It  is' a  modified  Buck's  extension.  The 
relief  from  discomfort  and  rapid  recovery  under  its  use  is  often  remarkable. 

Opportunity  to  demonstrate  it.  If  the  destruction  of 
the  adhesions  by  repeated  flexion  of  the  finger  by  passive 
motion,  supplemented  by  active  motion  with  the  help  of 
various  appliances  described  in  a  subsequent  chapter, 
which  I  have  used  with  more  or  less  success  at  various 


INVOLVEMENT  OF  THE  HAND  PROPER  437 

times,  does  not  succeed,  the  im])Iantation  of  adjacent 
connective-tissue  flaps  or  living  attached  tags  of  cartihige 
is  to  be  recommended  or  if  these  cannot  be  secured  the 
transplantation  of  a  pad  of  tissue  and  fat  from  a  distant 
part  of  the  body  may  be  used  with  some  assurance  of 
success. 

Suppuration  is  uncommon  in  the  mctacarpo-phalangeal 
joint,  but  here  also  resection  may  be  resorted  to  if  the 
tendon  is  intact.  If  this  complication  be  present  amputa- 
tion of  the  finger  is  generally  advisable. 

INVOLVEMENT  OF  THE  HAND  PROPER  AND  THE  METACARPALS 

AND  CARPALS. 

Pathology. — The  third  type  of  chronic  osseous  lesion 
is  that  in  which  the  bones  of  the  hand  proper  are  involved. 
Here,  unless  modified  by  an  original  wound  or  operative 
procedure,  the  picture  is  again  different,  owing  to  the 
dense  aponeurosis  upon  the  palmar  side  and  the  sheet  of 
dense  tissue  upon  the  dorsum  uniting  the  tendons  of  the 
extensor  communis  digitorum.  These  dense  sheets,  parti- 
cularly upon  the  palm,  prevent  the  free  egress  of  pus,  and, 
as  a  consequence,  it  is  more  likely  to  burrow  a  considerable 
distance  from  the  site  of  origin  before  exit  (Fig.  151). 
This  diffuses  the  reactive  inflammation,  and  even  if  the 
exit  is  found  near  the  site,  the  dense  sheet  prevents  the 
crater-like  elevation  of  granulation  tissue  noted  in  the 
second  or  phalangeal  type.  Hence,  we  are  more  likely 
to  find  a  diffuse  swelling  of  the  whole  palm  of  dorsum  with 
multiple  ostia,  any  of  which  may  be  open  for  a  time  and 
discharge,  while  another  may  be  closed.  There  is  often 
only  a  small  amount  of  granulation  tissue  about  the 
openings.  In  these  cases  of  early  osseous  involvement 
often  no  sinus  will  appear  upon  the  palmar  surface,  unless 
the  soft  tissues  of  the  palm  have  been  seriously  involved 
primarily,  or  the  infection  has  spread  into  the  wrist-joint, 
and  this  is  generally  preceded  by  palmar  phlegmon  or 


438 


SEQUELM  OF  IXFECTIOXS  OF  THE  HAND 


tenosynovitis.  Therefore,  in  these  patients  with  osteo- 
myehtis  of  the  metacarpal  bones,  dorsal  sinuses  are  most 
common.  They  may  appear  at  any  point  on  the  dorsum, 
but  have  a  predilection  for  the  sides  and  distal  part  near 
the  knuckles  (Fig.  152),  owing  to  the  dense  sheet  of  tissue 
before  mentioned.  It  is  a  well-known  fact,  however,  that 
frequently  this  sheet  has  areas  where  it  is  not  complete, 


Middle  palmar  space 


Lumbrical  mus.  with 
accompanying  nerve 
•  and  vessel^. 


Lumbrical  canal 


Fig.  150. — Note  the  direct  communication  of  the  lumbrical  canal  with  the 
middle  palmar  space  and  that  pus  spreading  from  the  middle  palmar  space 
will  pass  along  the  lumbrical  canal  into  the  lax  connective  tissue  of  the  web. 


particularly  in  the  lower  third  between  the  tendons;  and 
through  these  pus  may  discharge.  But  it  is  not  at  all  an 
uncommon  thing  to  see  a  sinus  ostium  at  either  side  over 
the  index  and  little  finger  metacar])al,  and  one  or  two  at 
the  distal  end  between  the  knuckles,  from  a  single  focus 
of  infection  in  either  the  middle  or  ring  metacarpal  (Fig. 
70),  as  will  be  shown  clearly  b\"  .v-ra>'  picture.     Again, 


INVOLVEMENT  OF  THE  HAND  PROPER 


439 


these  ostia  on  the  dorsum  at  the  knuckles  may  l)e  clue  to  a 
chronic  process  in  the  pahn  discliarging  through  the 
lumbrical  canals  (see  Fig.  151). 


J/fC/7 


Lumbrical  m.  in 
middle  palmar 
3 pace 


Fc^int  of  exit  of  pus 


Interosseous  /n. 
spread  ovei    bone 


Palmar  arch 

Blood  vessels  _ 
Lumbrical  m.  &  tend — 

Tledian  n.  &  ves. 

Flex:  long,  pol  m. 

Thenar  m. 


Epip^yJi^  of  bane 
__Jubaponevrotic  space 
Jadcutaneous  -space 


Ext   com.  tendon 
I/iierosse:  jeporaled 
6y  fojc i-al  j-efitum 


Middle  palmar 
space  filled  with 
pus 


/Metacarpals 
fladcal  a. 


Fig.  151. — Drawing  showing  the  relation  of  pus  in  the  middle  palmar  space 
to  the  tendons.  Also  showing  course  pus  pursues  in  its  course  along  the  lum- 
brical muscle  to  point  on  the  drosum  near  the  web.  Serial  sections  of  the  hand 
were  made  as  shown,  the  tissues  teased  out,  and  middle  palmar  space  filled  with 
plaster  of  Paris.  Sections  restored  to,  normal  position  and  sagittal  section  made 
between  ring  and  middle  metacarpal  of  all  sections  except  the  proximal.  Hea\y 
dotted  area  shoWs  position  pus  would  occup}'. 

So  far  as  I  have  observed,  there  is  no  peculiar  patho- 
logical destruction  of  the  metacarpal  bones  in  these 
cases   (Fig.    153).     There  is  one  clinical  fact,   however, 


440 


SEQUEL.E  OF  INFECTIONS  OF  THE  HAND 


worth  remembering  from  a  therapeutic  standpoint,  and 
that  is  the  relative  immunity  from  involvement  of  the 


DSCS 


FLP 


Fig.  152. — Schematic  drawing,  showing  pus  under  dorsal  aponeurosis  with 
ostium  at  the  side:  C,  site  of  discharge  of  pus;  DP  A,  deep  palmar  arch;  DSCS, 
dorsal  subcutaneous  space;  FLP,  flexor  longus  pollicis;  IDSAS,  infected  dorsal 
subaponeurotic  space;  IS,  indefinite  space;  ITS,  indefinite  thenar  space;  LM, 
lumbrical  muscle;  MPS,  middle  palmar  space;  OM,  osteitis  of  the  metacarpal; 
PF,  palmar  fascia;  TS,  thenar  space. 

metacarpo-phalangeal  joint;  this  is  possibly  owing  to  the 
dense  ligaments  surrounding  the  joint,  Avhich  protect  it 


Fig.  153. — Metacarpal  removed  from  hand  of  patient  who  suffered  an  osteo- 
myelitis following  a  severe  tonsillitis. 


from  invasion  by  way  of  the  synovial  sheath  and  adjacent 
phlegmons.     As  a  consequence  of  this  we  are  often  able 


INVOLVEMENT  OF  THE  HAND  PROPER  441 

to  preserve  a  functionating  finger,  although  a  considerable 
destruction  of  the  metacaq^al  may  be  present;  isolated 
inflammation  of  a  metacarpal  is  uncommon  except  in 
tuberculosis  or  syphilis.  It  should  be  noted  that  we  may 
see  isolated  osteomyelitis  as  a  part  of  a  systemic  infection, 
comparable  to  the  osteomyelitis  seen  in  other  bones  of  the 
body,  as  the  femur.  A  photograph  of  such  an  osteomye- 
litic  destruction  is  herewith  presented.  The  patient  had 
suffered  from  a  severe  tonsillitis  and  developed  tenderness 
on  the  dorsum  of  the  hand  over  the  junction  of  the  distal 
epiphysis  and  the  diaphysis  of  the  ring  finger  meta- 
carpal. At  the  operation  the  entire  diaphysis  of  this 
bone  was  removed,  care  being  taken  to  save  the  epiphyses 
to   prevent    sequential    involvement   of    the   joints    (see 

Fig.  153)- 

Involvement  of  the  wrist-joint  in  chronic  processes  is 
characterized  by  multiple  foci  on  both  the  dorsal  and 
palmar  surface. 

Case  XLIX. — S.,  Post-Graduate  Hospital,  December, 
19 10.  The  patient  suffered  from  a  previous  tendon-sheath 
infection  of  the  ulnar  and  radial  sheaths.  I  saw  him  after 
three  months  of  chronic  infection,  when  there  were  multiple 
sinuses  both  on  the  dorsum  and  flexor  surface  of  the  wrist 
from  the  joint,  with  lateral  and  distal  sinuses  upon  the  dorsum 
of  the  hand  from  osteomyelitis  of  the  metacarpals  of  the  index, 
middle,  and  little  fingers.  There  was  no  involvement  of  the 
metacarpo-phalangeal  articulations,  in  spite  of  the  long- 
continued  infection  and  extensive  osteomyelitis.  The  x-ray 
picture  clearly  showed  the  location  of  the  foci.  All  of  the 
carpal  bones  were  remo^'ed  and  the  necrotic  part  of  the  meta- 
carpals. _^  The  hand  rapidly  recovered.  All  discharge  ceased 
within  four  weeks.    Almost  all  function  was  lost  (Fig.  154). 

I  have  been  surprised  to  find  that  now  after  two  3-ears 
he  has  developed  considerable  function  of  the  fingers  and 
hand,  so  that  he  can  hold  a  glass  and  perform  other  gross 
functions  with  the  hand  as  well  as  write,  hold  a  knife  and 


442  SEQUELS  OF  INFECTJOXS  OF  THE  HAXD 


Fig.  154. — .V-ray  photograph  ol  hand  (Case  XLIX).  Necrotic  bone  was 
removed  from  the  wrist  anrl  the  three  metacarpals.  (See  photograph  of  hand 
showing  present  function,  Fig.   155.) 


IXVOLVEMEXT  OF  THE  HAM)  PROPER  443 

fork,  and  do  other  similar  acts  (Fig.  155).      I  liaxe  had  a 
similar  cx])erience  in  two  other  cases. 

The  following"  history  of  a  patient  in  the  practice  of 
Dr.  H.  B.  Baumgarth,  with  whom  I  saw  the  case  in  con- 
sultation, illustrates  the  course  of  these  chronic  cases  when 
untreated. 


Fig.  155.^Hand  of  patient  described  in  Case  XLIX  two  years  after  operation. 

Case  L. — Mrs.  G.  received  infection  September  5,  1904. 
at  web  betvveen  the  middle  and  ring  fingers.  The  patient 
consulted  a  magnetic  healer  and  remained  under  his  care  for 
seven  weeks,  when  she  applied  to  Dr.  Baumgarth,  who 
obtained  the  following  history  and  drained  the  hand  properly 
Twenty-one  days  after  the  receipt  of  the  infection,  point  2. 
noticed  on  the  dorsum,  opened  up;  a  few  days  fater,  points 
3  and  4  opened,  slightly  more  on  the  dorsal  surface  than  on 
the  palmar.  Points  5,  6,  7,  and  8  appeared  successively  in 
the  next  few  days.  After  an  interval  of  a  few  days,  points  9 
and  10  appeared  followed  in  succession  by  12  and  13,  and 
after  an  inter^-al  of  several  days,   14,   15,  and  16,  at  which 


444  SEQUELS  OF  IXFECTIOXS  OF  THE  HAND 

time  the  patient  applied  to  Dr.  Baumgarth,  who  thoroughly 
drained  the  pockets,  and  the  patient  made  a  tardy  recovery. 
The  atrophy  of  the  distal  phalanx  of  the  index  finger  is  due 
to  a  previous  felon.  The  atrophy  of  the  other  fingers  followed 
as  a  sequence  of  the  present  infection. 

On  February  25  adhesions  were  broken  up  under  nitrous 
oxide,  which  benefited  the  movement  of  the  finger  and  wrist 
to  a  slight  extent  only. 

A  careful  study  of  this  case  serves  to  point  out  the 
pathological  sequence  which  occurred  as  a  result  of  the 
infection  (Fig.  156).  Points  i  and  2  were  the  original 
site  of  the  infection,  which  spread  from  there,  without 
doubt  by  lymphatic  extension  or  continuity  of  tissue, 
along  the  lumbrical  canal  into  the  midpalmar  space; 
from  here  in  turn  it  retraced  its  course  through  the 
lumbrical  canals  to  the  base  of  the  index  finger,  point 
4,  and  the  base  of  the  little  finger,  point  6.  The  ulnar 
bursa  evidently  became  involved,  and  points  9  and  10 
show  the  site  of  rupture  from  the  sheath,  the  other  areas 
at  the  base  of  the  palm  developing  as  a  rupture  of  the 
proximal  end  of  this  bursa.  This  point  was  corroborated 
by  Dr.  Baumgarth  at  the  time  of  operation,  since  pus  was 
found  above  the  annular  ligament  in  this  synovial  sac. 
It  is  to  be  noted  that  all  the  primary  points  of  rupture 
from  I  to  8  appeared  upon  the  dorsal  surface  of  the  base 
of  the  webs  of  the  fingers.  The  characteristic  claw-hand 
seen  in   neglected   tendon-sheath   infection   is   shown   in 

Fig-  157- 

In  those  exceptional  cases  in  which  the  pus  has  extended 
to  the  dorsum  between  the  metacarpal  bones,  there  is 
generally  some  destruction  of  bone  requiring  attention. 
It  is  at  times  seen  in  advanced  cases  accompanying  wrist- 
joint  invasion. 

Treatment  of  Cases  Involving  the  Hand  Proper. 
— The  treatment  in  those  patients  in  whom  the  chronic 
process  lies  in  the  palm  may  be  confusing.     We  should 


LWOLVEMEXT  OF   THE  IIAXD  PROPER 


445 


determine  first  the  location  of  the  pus.  Does  it  lie  in  the 
synovial  sheaths  or  in  the  fascial  space?  Are  the  bones 
or  the  wrist-joint  involved?  While  theoretically  difficult 
to  determine,  it  is  not  so  confusing  as  in  the  acute  cases, 
since  there  are  generally  sinuses  which  can  be  followed 
down  to  the  hidden  pockets.  X-ray  photographs  may 
show  necrotic  bone.  Complete  anesthesia  is  essential. 
No  operation  upon  infected  hands  should  be  undertaken 


Fig.  156. — Photograph  of  Case  L.  Figure  numbers  on  the  photograph  repre- 
sent the  various  sinuses  and  their  approximate  order  of  development  b^'  which 
the  course  of  the  infection  can  be  traced. 


without  it.  The  ramifications  should  be  followed  up 
carefully  and  with  patience.  I  shall  not  speak  in  detail 
of  the  factors  which  lead  us  to  diagnosticate  the  presence 
of  pus  in  the  various  sites,  since  this  has  already  been 
discussed  exhaustively^  in  the  previous  chapters. 

Various  sinuses  leading  from  the  tendons  to  the  surface 
will  be  followed  down  to  the  respective  synovial  sheaths. 
The  sinuses  found  at  the  most  proximal  point  of  the  finger 


446  SEQUELM  OF  INFECTIONS  OF  THE  HAND 

sheaths  designate  the  corresponding  sheath,  and  this 
should  be  cut  down  upon  and  followed  distally  along  the 
finger  until  every  part  of  the  tendon  bathed  in  pus  is 
exposed.  Where  the  little  finger  tendon  is  involved,  the 
extension  of  the  sheath  in  the  palm  should  be  borne  in 
mind,  and  the  opening  continued  proximally  over  this 
when  the  grooved  director  inserted  into  the  infected 
sheath  on  the  little  finger  passes  up  into  this  without 
obstruction.     Here  the  sheath  should  be  opened  through- 


FiG.  157. — Photograph  showing  claw-hand  in  neglected  tendon-sheath  infection. 

out  its  extent  up  to  the  annular  ligament,  the  incision 
lying  to  the  ulnar  side  of  the  tendons.  The  incision  should 
end  at  the  annular  ligament  until  the  decision  has  been 
made  as  to  whether  the  infection  has  extended  under  this 
into  the  proximal  end  of  the  sheath  above  the  annular 
ligament.  If  this  is  diagnosticated  it  will  be  found  more 
satisfactory  to  drain  the  upper  end  of  the  sheath  by  inci- 
sions upon  the  ulnar  and  radial  side  of  the  forearm  as 
described  in  the  chapter  on  Forearm  Involvement,  rather 
than  by  cutting  the  anterior  annular  ligament.      It  is  not 


INVOLVEMENT  OF  THE  HAND  PROPER 


447 


wise  to  open  the  sheath  on  the  volar  surface  above  and 
below  the  Hp:amcnt  and  leave  this  latter  intact.  Having 
thoroughly  opened  this,  the  question  thus  arises:  Has 
the  radial  bursa,  i.  e.,  the  sheath  of  the  flexor  longus 
pollicis,  become  involved?  If  so,  this  must  be  opened 
throughout  its  extent  down  to  a  thumb's  breadth  distal 
to  the  annular  ligament.  The  incision  should  stop  here 
for  fear  of  injuring  the  motor  nerve  to  the  thenar  area. 

If  the  tendons  have  become  necrotic,  removal  is  indi- 
cated; on  the  other  hand,  one  is  often  surprised  at  the 


Fig.  158. — Showing  Klapp's  aspiration  cup  used  in  some  old  chronic  infections 

of  the  fingers. 


amount  of  vitality  present  in  the  tendons  which  have  lost 
their  synovial  covering,  therefore  after  opening  a  sheath 
considerable  conservatism  is  justifiable  when  it  comes  to 
a  question  of  preserving  or  removing  a  tendon.  Some  of 
the  chronic  sluggish  processes  in  the  fingers  have  seemed 
to  be  benefited  by  the  Klapp  suction  cup  (Fig.  158). 

If  the  fascial  spaces  are  involved,  they  should  be  drained 
after  the  methods  described  in  Chapter  XVII. 

In  considering  the  treatment  of  those  cases  in  which 
the  suppurating  ostia  appear  upon  the  dorsum,  particu- 
larly between  the  knuckles,  I  have  already  pointed  out 
that  in  a  majority  of  cases  these  are  really  sinuses  leading 


448  SEQUELS  OF  IXFECTIONS  OF   THE  HAND 

from  the  palm  along  the  lumbrical  canals  (Fig.  151),  and 
the  perfect  drainage  of  the  palm  along  the  lumbrical 
canals,  as  already  mentioned,  will  end  in  rapid  recovery 
if  uncomplicated  by  tendon  or  bone  involvement. 

If  the  bones  of  the  hand  or  wrist  are  involved,  they 
should  be  removed  or  the  necrotic  part  curetted  out. 
In  treating  the  wrist-joint  the  general  principles  as  to 
the  removal  of  bones,  which  have  been  enunciated  in 
Chapter  XXVIII  when  dealing  with  carpal  involvement, 
should  be  borne  in  mind.  These  should  not,  however, 
interefere  with  the  paramount  rule  that  all  dead  bone 
should  be  removed. 

ATROPHY  AND    CONTRACTURE. 

One  of  the  most  lamentable  consequences  of  the  severe 
or  untreated  types  of  acute  infections  in  the  hand  is  seen 
in  the  contractures  producing  deformity  and  disability. 
In  the  severer  types  most  extensive  pathological  changes 
are  found.  The  anatomical  and  clinical  evidence  already 
adduced  shows  the  tendency  for  the  infection  to  spread 
along  the  bloodvessels  and  nerves.  This  leads  to  com- 
pression of  the  bloodvessels  and  lymphatics  producing  a 
persisting  distal  edema  while  the  contraction  of  the  scar 
tissue  about  the  nerves  leads  to  trophic  changes.  Mas- 
sage, passive  motion,  and  constant  use  of  the  hand  carried 
out  systematically  under  the  careful  supervision  of  the 
surgeon  will  aid  nature.  Adhesions  in  the  joints,  when 
they  are  not  the  result  of  the  destruction  of  the  synovial 
coverings,  may  be  treated  by  repeated  non-violent  passive 
movements  under  nitrous  oxide  anesthesia,  or  by  the 
various  appliances  designed  to  produce  passive  motion, 
as  for  instance  those  which  act  by  exhausting  the  air,  and 
hence,  in  addition  to  producing  mobility,  favor  active 
congestion  of  the  parts  or  some  of  the  various  procedures 
noted  in  the  following  chapter. 

The    amount    of    function    secured    by    these    hands. 


ATROPHY  AND  CONTRACTURE  449 

apparently    irretrievably    injured    by    scar    tissue    and 

destruction  of  nerves  and  tendons,  is  above  expectation 

if   treatment    such    as    suggested    above    is    persistently 

carried  out. 

It  frequently  happens  in  the  severest  types,  especially 

in  tenosynovitis,  that  owing  to  late  or  improper  treatment 

or    other    factors,    great    disability    ensues    demanding 

plastic  procedures  if  any  impro\'ement  is  to  be  secured. 

It  has  been  my  fortune  to  operate  upon  a  number  of  such 

cases  in  an  endeavor  to  restore  to  the  patient  as  much 

of  the  destro^'ed  function  as  possible.     One  who  has  not 

had  this  experience  can  hardly  realize  the  extent  of  the 

destruction  of  tissue  and  the  distortion  of  the  anatomical 

structures  found  as  a  result  of  the  infection.     In  those 

cases  in  which  the  tendon  sheaths  are  involved — and  these 

are  by  all  odds  the  most  serious  type  one  finds— the 

synovial  sheath  is  entirely  obliterated;   the  endothelial 

lining  is  entirely  lost;  there  is  a  complete  fibrous  union 

between  the  tendon  and  its  sheath  throughout  its  extent; 

and  incident  to  the  flexed  position  of  the  hand  and  the 

changes  characteristic  of  all  connective  tissue,  the  tendons 

have  been  shortened.     At  the  wrist  under  the  anterior 

annular  ligament,   the  ulnar  and  radial  bursae  and  the 

intermediate  sheaths  are  completely  obliterated  and  the 

majority-  of  the  tendons  are  indistinguishable  as  tendons 

from  the  surrounding  connective  tissue.     A  few  of  the 

superficial  flexor  tendons  may  be  dissected  out  from  this 

scar   tissue   and    recognized.     The   flexors   of   the   little 

finger  are  frequently  completely  lost  and  the  same  holds 

true  of  the  flexor  of  the  thumb.     The  median  ner\'e  may 

be  completely  destroyed  for  some  distance.     The  anterior 

annular   ligament   is   involved   in   the   connective-tissue 

formation.     In  the  palm,  the  tendons  of  the  index,  middle, 

and  ring  fingers  may  frequently  be  isolated  and  less  often 

those  of  the  little  finger  and  thumb.     On  the  dorsum, 

particularly  if  ill-advised  incisions  have  been  made  here, 
29 


450  SEQUELS  OF  INFECTIONS  OF  THE  HAND 

the  tendons  are  a  part  of  the  connective-tissue  mass 
although  more  easily  dissected  out  than  those  upon  the 
flexor  surface.  In  the  forearm,  connective-tissue  contrac- 
tion has  taken  place  about  the  median  and  ulnar  nerves 
and  the  ulnar  artery,  compressing  them  and  binding  the 
muscles  together.  Moreover,  the  tendons  above  the 
wrist-joint  and  the  deep  flexor  muscles  are  united  by  firm 
connective- tissue  bands  to  the  pronator  quadratus  and  the 
interosseous  septum. 

Joint  changes  have  also  occurred.  These  are  noticeable 
in  the  interphalangeal,  metacarpo-phalangeal,  and  wrist- 
joints.  Owing  to  the  inflammation  about  the  phalangeal 
joints,  they  are  rather  firmly  fixed  in  flexion  while  the 
metacarpo-phalangeal  joints  are  generally  fixed  in  over- 
extension with  periarticular  contraction  and  intra-articu- 
lar  adhesions,  frequently  not  insurmountable,  but  difficult 
to  deal  with.  At  the  wrist-joint,  in  the  severest  cases, 
considerable  destruction  of  the  carpal  bones  may  have 
occurred,  ending  in  ankylosis  of  the  joint,  often  in  a 
bizarre  position. 

The  muscles  have  also  undergone  change.  Those  in 
the  forearm  have  lost  their  tone,  fibrosis  has  taken  place 
and,  hence,  although  active  are  impaired.  The  most 
unfortunate  sequella,  however,  is  that  produced  in  the 
lumbrical  and  interosseous  muscles.  These  are  frequently 
entirely  destroyed,  due  either  to  inflammation,  destruc- 
tion of  innervation,  or  a  lack  of  blood  supply.  The  nerves 
have  also  partaken  of  the  general  devastation  owing  to  the 
direct  spread  of  the  infection  from  the  hand  into  the  fore- 
arm along  both  the  median  and  ulnar  nerves.  The  nerves 
are  surrounded  by  connective  tissue  and  their  vitality 
and  function  impaired.  In  the  carpal  canal  it  is  fre- 
quently impossible  without  the  greatest  of  care  to  dis- 
tinguish the  nerves  from  the  surrounding  scar  tissue  of  the 
tendons.  If  there  has  been  pus  in  the  middle  palmar  and 
thenar  spaces,  the  digital  branches  of  the  nerves  have  also 


ATROPHY  AXD  CONTRACTURE  451 

been  pressed  upon.  The  bloodvessels  have  suffered  in  the 
general  connective-tissue  contraction.  The  skin  is  glossy 
and  shows  the  effect  of  a  lack  of  both  nerve  and  blood 
supply.  The  pathological  picture,  therefore,  is  one  of 
destruction  of  nerv'e  and  blood  supply  with  massive  con- 
nective-tissue contraction  about  structures  that  have  a 
most  delicate  function. 

As  to  the  clinical  appearance,  one  sees  a  glossy  skin  with 
atrophied  h\pothenar,  thenar,  and  forearm  muscles  and 
shrunken  intermetacarpal  spaces,  the  thumb  frequently 
abducted  and  fixed,  the  fingers  flexed  upon  themselves 
and  extended  on  the  hand,  with  fibrous  ankylosis  of  the 
finger- joints,  and  frequently  osseous  ankylosis  at  the 
wrist-joint  producing  an  immobile,  shrunken  claw-hand, 
absolutely  functionless  and  useless.  Moreover,  owing  to 
the  poor  nerx'e  and  blood  supply,  the  hand  is  often  the 
seat  of  ulcers,  frost-bites,  and  inadvertent  burns.  We 
have  here  drawn  the  picture  of  the  worst  type  seen  in 
these  cases,  that  produced  particularly  by  neglected 
ulnar  and  radial  bursal  infections  in  which  the  pus  has 
been  allowed  to  rupture  into  the  forearm  and  frequently 
into  the  palm  of  the  hand  and  the  wrist-joint.  Those 
cases  in  which  the  bursae  are  opened  promptly  end  fre- 
quently with  contracture  of  the  little  finger  but  a  fairly 
satisfactory  result  as  far  as  function  in  the  hand  as  a 
whole  is  concerned. 

Patients  presenting  themselves  have  generally  had  their 
infections  some  months  or  years  before  and  have  tried  all 
manner  of  massage  without  benefit.  Indeed,  in  view  of 
the  pathological  picture  presented  in  these  cases,  it  would 
be  most  remarkable  if  by  such  procedures  one  could 
produce  any  result. 

For  a  number  of  years  a  study  has  been  carried  on  in 
these  cases  with  the  hope  that  some  surgical  procedure 
might  be  developed  that  would  offer  relief  to  these  suf- 
ferers.    Owing  to  the  fact  that  it  takes  a  comparatively 


452  SEQUELM  OF  INFECTIONS  OF  THE  HAND 

long  time  to  obtain  results  and  that  not  only  must  one 
correct  the  condition,  but  the  muscle  tissue,  nerves,  and 
other  structures  must  regenerate,  it  is  difficult  to  deter- 
mine what  can  be  hoped  for  in  these  cases.  Moreover, 
owing  to  the  fact  that  not  much  can  be  definitely  promised, 
it  has  seemed  wise  to  restrict  any  procedures,  which  must 
of  necessity  be  more  or  less  of  an  experimental  nature,  to 
those  most  serious  cases  in  which  no  function  is  present 


Fig.  159. — Photograph  showing  result  of  operation  for  anchylosis  of  proximal 
intcrphalangeal  joint  and  loss  of  flexor  tendons. 

and  in  which  no  hope  can  be  offered  that  the  hand  w  ill 
be  better  without  some  intervention.  As  a  result  of  this 
study,  however,  it  would  seem  justifiable  to  state  that  a 
considerable  degree  of  function  can  be  secured  in  a  great 
majority  of  these  otherwise  hopeless  cases,  and  in  those 
less  seriously  involved  where  the  patient  has  the  time  and 
the  desire  to  persevere,  much  more  can  be  secured.  If  the 
operations  are  carefully  performed,  there  will  be  a  mini- 


ATROPHY  AND  CONTRACTURE 


453 


mum  of  danger  of  impairing  what  little  function  may  1)e 
present. 

In  those  cases  in  which  the  infection  has  been  upon  the 
dorsum  of  the  hand  alone,  incisions  may  be  made  to  either 


Fig.  160.— Restoration  of  tendon  by  use  of  silk  with  fat  transplant  about  it. 
Both  the  flexor  sublimis  and  the  flexor  profundus  were  lost.  Restoration  of  the 
flexor  sublimis  alone.     See  Fig.  161. 

side  of  the  interwoven  dorsal  tendons,  and  a  flap  of  fat 
inserted  between  the  tendons  and  the  bone  and  between 
the  tendons  and  the  skin.  This  flap  of  fat  should  not  be 
too  thick,  since  it  would  then  be  difficult  to  close  the  skin 


454  SEQUELS  OF  INFECTIONS  OF  THE  HAND 

wound.  If  the  techniciue  is  properly  carried  out,  such 
adhesions  can  be  ahnost  entirely  eradicated  and  a  practi- 
cally complete  function  restored.  Where  we  have  mid- 
palmar  adhesions  without  an  inflammation  of  the  tendon 
sheaths  a  like  good  result  can  generally  be  promised. 
Here,  however,  the  tendons,  lumbrical  muscles,  the  nerves, 
and  the  bloodvessels,  must  be  dissected  out  from  the  scar 
tissue  with  the  greatest  of  patience,  and  flaps  of  fat  from 
some  other  portion  of  the  body  transplanted  both  above 
and  below  the  tendons.     Especial  care  should  be  exer- 


FiG.  161. — Shows  result  after  some  months.  Photograph  of  hand  in  which 
there  was  loss  of  the  flexor  sublimis  and  flexor  profundus  tendon  of  the  index 
finger.  Figure  in  upper  left  hand  corner  represents  finger  before  operation.  The 
other  photograph  shows  various  operations  that  can  be  performed  by  patient 
with  finger.     See  Fig.  160. 

cised  to  dissect  out  the  lumbrical  muscles.  In  fastening 
these  flaps  of  fat  about  the  muscles  and  about  the  nerves 
and  bloodvessels,  the  finest  obtainable  catgut  or  silk  is 
used  and  as  few  sutures  as  possible  placed. 

In  those  cases  in  which  the  tendon  sheaths  of  the 
fingers  have  been  the  source  of  infection  and  in  which  but 
one  finger  has  been  involved,  if  the  patient  is  a  working- 
man  or  if  time  of  convalescence  is  an  important  factor  to 
the  patient,  an  amputation  is  advisable.  If,  however, 
time  is  not  a  factor  and  a  cosmetic  result  is  much  desired, 


ATROPHV  AND  CONTRACTURE 


455 


plastic  ()])erativc  i^rocedures  offer  sonic  hope  of  moderate 
or  complete  result.  I  have  operated  upon  several  of 
such  patients.     In  one  patient  a  tendon  was  restored  by 


Fig.  162. — Representation  of  restoration  of  extensor  Jongus  pollicis  by  silk  with 
fat  transplant  above  it.  Over  two  inches  of  tendon  were  lost.   See  Fig.  163. 


Fig.  163. — Photograph  shows  various  motions  possible  with  restored  tendon  as 
shown  in  Fig.  162.     Complete  function  of  all  phalanges  is  present. 


456  SEQUELS  OF  INFECTIONS  OF  THE  HAND 

means  of  silk  and  a  plastic  on  the  interphalangeal  joint 
carried  out  by  the  transplantation  of  tissue.  The  result  of 
this  double  operation  is  shown  in  Fig.  159.  In  another 
(Figs.  160  and  161)  one  of  the  two  flexor  tendons  of  the 
index  finger  was  restored  by  silk  strands  with  excellent 
function,  while  in  a  third  the  destroyed  extensor  longus 
pollicis  was  restored  by  strands  of  silk  with  the  perfect 
function  as  shown  in  Figs.  162  and  163.  The  anchylosed 
joint  is  opened  freely  and  sufficient  bone  excised  to  permit 
free  motion,  due  consideration  being  given  to  maintaining 
the  proper  contour  of  the  articular  surfaces.  If  adjacent 
connective  tissue  or  cartilage  can  be  turned  into  the  joint 
this  is  done;  if,  however,  this  is  not  possible  a  free  trans- 
plant of  fat  is  made.  The  restoration  of  the  tendon  where 
it  is  lost  and  where  there  is  an  obliteration  of  the  tendon 
sheath  is  naturally  attended  with  difficulty  and  I  have 
been  content  to  endeavor  to  restore  one  tendon — the  deep 
flexor  if  possible.  This  I  have  done  by  passing  strands 
of  silk  from  the  end  of  the  tendon  in  the  hand  and  to 
either  the  distal  end  of  the  middle  phalanx  or  the  proximal 
end  of  the  distal — generally  the  former.  The  finger  is 
drawn  down  into  marked  flexion,  the  silk  surrounded  by 
fat,  the  incision  upon  the  finger  being  made  upon  the  side 
rather  than  down  the  midline  so  that  the  action  of  the 
new  made  tendon  will  not  be  upon  the  line  of  suture. 
Early  active  and  passive  motion  is  insisted  upon,  beginning 
in  a  few  days  after  the  operation.  While  the  operation 
is  attended  by  many  results  only  partially  successful,  at 
times  brilliant  results  have  been  attained. 

It  has  been  my  experience  to.  have  several  cases  in 
which  the  patient  had  an  ankylosis  of  the  wrist-joint 
with  or  without  inflammation  of  the  tendons.  In  those 
cases  in  which  the  wrist-joint  is  ankylosed,  without 
serious  inflammation  of  the  tendons,  it  has  been  possible 
to  restore  complete  function. 

In  the  earlier  cases  it  was  my  custom  to  remove  but  one 


ATROPHY  AND  CONTRACTURE  457 

row  of  the  cari)al  bones,  but  hiter  (j.\])encncc  has  taiiL;lit 
me  that  it  is  wiser  to  remove  both  the  proximal  and  cHstal 
row  and  all  the  intervening  tissue.  Into  this  excavated 
joint,  pads  of  fat  taken  from  the  abdomen  or  leg  have  been 
introduced.  It  would  seem  to  be  inadvisable  to  overpack 
the  joint,  but  on  the  other  hand,  it  should  not  be  under- 
filled. Some  care  must  be  exercised  not  to  tear  into  the 
tendon  sheaths  in  front  if  they  have  not  been  involved  in 
a  previous  infection.  It  has  been  possible  to  remove  the 
bones  through  a  lateral  dorsal  incision  at  one  side  only. 
As  soon  as  the  wound  is  healed,  the  patient  is  urged  to 
use  the  hand  as  much  as  possible,  and  passi\"e  motion 
is  begun,  but  no  violent  tearing  is  indulged  in.  These 
cases  have  been  by  far  the  most  satisfactory  that  have 
come  to  me. 

We  now  come  to  that  type  in  which,  while  there  has 
been  a  tenosynovitis  in  the  little  finger  and  thumb  with 
the  radial  and  ulnar  bursse  involved,  there  has  not 
developed  an  abscess  in  the  palm  of  the  hand;  at  least 
not  extensive  enough  to  produce  secondary  adhesions, 
and  there  is  consequently  a  moderate  amount  of  function 
of  the  middle,  index,  and  ring  fingers.  Every  gradation 
of  function  may  here  be  seen.  If  the  condition  has  been 
treated  early  so  much  function  is  secured  in  these  fingers 
that  any  operative  procedure  is  inadvisable.  The  more 
serious  types  of  these  gradually  shade  into  the  most  serious 
types  of  hand  infection,  presenting  the  contractions  and 
adhesions  I  have  described  above  and  with  which  I  have 
had  the  larger  part  of  my  experience.  In  these  cases 
the  patient  must  understand  that  at  least  two  operations 
will  be  necessary  and  probably  three  or  four  before  he  can 
be  discharged  with  a  maximum  amount  of  benefit.  He 
must  understand  that  he  will  be  under  treatment  for  a 
number  of  months,  and  he  must  also  understand  that  the 
ultimate  function  to  be  obtained,  while  it  may  be  fairly 
good,  will  never  be  as  satisfactory  as  before  the  infection. 


458  SEQUELM  OF  IXFECTIOXS  OF  THE  IIAXD 

If  ankylosis  at  the  wrist-joint  is  present,  it  is  my  habit 
at  the  first  operation  to  dissect  out  the  tendons  on  the 
back  of  the  hand,  open  the  wrist-joint  and  remove  the 
bones,  and  transplant  fat  into  the  joint  about  the  tendons 
on  the  dorsum.  The  second  operation,  and  by  far  the 
most  difficult,  is  upon  the  flexor  surface.  Anesthesia  by 
the  Kulenkampf  method,  injection  of  the  nerv^es  above  the 
clavicle,  or  if  this  fails  along  their  course  is  to  be  preferred 
to  general  anesthesia.  The  Martin  bandage  is  generally 
applied  at  the  beginning  of  the  operation  but  it  can  be 
dispensed  with  after  a  short  time  and  should  yiever  he  left 
071  longer  than  an  hour  without  releasing  it  at  least 
temporarily.  Lately  I  have  substituted  the  ordinary 
blood-pressure  apparatus  for  the  Martin  bandage.  An 
exact  pressure  can  be  maintained  by  this  with  less  danger 
of  pressure  injury  to  the  nerves,  but  here  also  the  rule  of 
releasing  the  pressure  at  least  ever\'  hour  is  maintained. 
A  long  incision  is  made  over  the  ulnar  half  of  the  palm  of 
the  hand  and  onto  the  forearm.  The  anterior  annular 
ligament  is  cut.  The  first  endeavor  should  be  to  find  the 
median  and  ulnar  nerves  in  the  forearm  and  trace  them 
into  the  palm.  In  this  step  it  is  my  custom  to  use  magni- 
fying spectacles,  for  I  have  found  that  they  are  the  only 
means  by  which  I  can  surely  identify  the  nerves  in  a  mass 
of  scar  tissue.  Five  times  in  cases  sent  to  me  by  other 
surgeons  I  found  the  median  nerv^e  had  been  sutured 
end-to-end  with  a  tendon  in  traumatic  cases,  showing 
that  in  fairly  normal  conditions  the  differentiation  may 
be  difficult.  These  nerves  are  dissected  out  of  their 
surrounding  tissues  well  down  into  the  hand,  the  greatest 
care  being  used  to  avoid  cutting  any  of  the  branches  in 
the  palm.  This  part  of  the  procedure  is  of  vital  import- 
ance. \\'here  bloodvessels  are  met,  especial  care  is  taken 
to  preserA'e  them. 

The  tendons  as  far  as  possible  are  dissected  out  of  the 
mass  of  connective  tissue.     It  is  frequently  necessary  to 


ATROPHY  AXD  CONTRACTURE  459 

use  the  connective  tissue  itself  as  tendons,  dissecting 
strands  which,  although  ]:)resentini^  no  evidence  of  pre\'ious 
tendon  function,  will  work  satisfactorih-.  Where  the 
tendons  are  completely  destroyed  and  cannot  be  identi- 
fied, and  no  connective  tissue  is  left  from  which  to  make 
them,  strands  of  silk  can  be  inserted,  but  this  contingency 
should  be  avoided  if  possible.  The  hook  of  the  unci- 
form ma\'  so  interfere  at  times  as  to  make  its  removal 
necessary  if  it  has  not  been  removed  during  a  previous 
operation  on  the  joint.  The  tendons  are  dissected  down 
to  the  lingers  and  flaps  of  fat,  split  in  three  la^-ers  if 
possible,  are  inserted;  one  la\'er  being  under  the  tendons, 
one  between  the  superficial  and  deep  tendons,  and  one 
above.  It  is  generally  impossible  to  do  this  with  as 
great  attention  to  detail  in  protecting  the  individual 
digital  nerves  as  one  could  hope.  Here,  again,  an 
attempt  should  be  made  to  preserve  the  lumbrical  muscles 
if  possible.  The  fat  pad  should  extend  well  into  the  fore- 
arm. The  wounds  are  then  closed  tightly.  It  is  wise  to 
draw  attention  to  the  necessity  of  the  most  scrupulous 
care  in  our  technique,  since  such  long  and  tedious  dissec- 
tion in  tissue  of  low  vitality  is  especially  favorable  to  the 
development  of  infection. 

As  a  final  step  in  some,  and  as  an  individual  step  in 
other  cases,  a  resection  of  both  the  ulna  and  the  radius, 
with  the  removal  of  3  or  4  cm.  has  aided  materially  in 
producing  satisfactory'  results.  In  some  cases,  however, 
this  step  will  not  be  of  any  benefit;  therefore  it  should 
not  be  resorted  to  without  careful  study. 

It  has  been  my  experience  to  treat  some  cases  in  which 
there  had" been  lacerated  wounds  of  the  hand  and  forearm 
with  a  severing  of  nerA'es  or  tendons,  followed  by  infection 
with  contracture  of  the  hand  as  well  as  the  forearm. 
Two  of  these  cases  have  also  suffered  from  extensive 
destruction  of  palmar  fascia  with  infection.  In  these 
cases  a  transplant  of  skin  as  well  as  fatty  tissue  is  applied. 


460  SEQUELM  OF  INFECTIONS  OF  THE  HAND 

In  the  palmar  case  the  hand  was  inserted  into  a  pocket 
over  the  hip  after  the  tendons  had  been  dissected  out. 
The  result  was  not  particularly  satisfactory,  however, 
until  a  subsequent  ojieration  in  which  I  loosened  the 
tendons  again  and  transplanted  them  into  the  fat  which 
still  remained  adherent  to  the  transplanted  flap.  One 
error  was  made  in  this  case  in  that  the  portion  of  skin 
chosen  had  considerable  hair  upon  it,  and,  since  the 
patient  was  a  girl,  it  created  some  embarrassment,  but 
after  two- or  three  years,  though  the  hair  follicles  still 
developed  hair,  it  was  of  such  a  fine  character  as  to  be  of 
no  importance  (Fig.  i66,  167,  and  168). 

Another  fact  that  has  been  impressed  upon  me  not 
alone  by  this  case  but  by  others  of  the  same  nature  upon 
which  I  have  transplanted  skin,  is  that  the  subcutaneous 
fat  which  I  had  previously  understood  would  be  rapidly 
absorbed  in  the  palmar  flap,  remained  for  a  number  of 
years.  In  one  of  the  forearm  cases,  after  the  tendons  and 
nerves  were  identified,  sutured,  and  isolated  from  the 
connective-tissue  mass,  a  transverse  incision  was  made 
upon  the  abdomen  ^\ith  its  convexity  upward,  the  skin 
edge  of  the  everted  flap  was  sutured  to  the  ulnar  side  of 
the  skin  wound  on  the  forearm.  The  subcutaneous  fat 
was  cut  in  sheets  parallel  to  the  skin  but  left  attached 
at  the  base  and  wrapped  about  the  tendons  and  nerves, 
the  ends  of  the  skin  flap  being  sutured  to  the  distal  and 
proximal  ends  of  the  forearm  wound.  At  a  subsequent 
period  the  skin  was  detached  from  the  body  and  the  cut 
edge  sutured  to  the  radial  side  of  the  wound.  This 
patient  had  suffered  a  most  serious  infection  and  had  in 
addition  to  the  contracture  of  the  hand,  an  ankylosis 
of  the  wrist-joint.  Photographs  of  this  patient  are  here- 
with presented  (Figs.  164  and  165).  The  result,  while 
not  anatomically  perfect  and  one  which  I  believe  that  now 
with  my  added  experience  could  be  improved,  is  most 
satisfactory  to  the  patient  since  he  is  able  to  feed  himself 


ATROPHY  AND  CONTRACTURE 


4()1 


and  use  his  hand  in  eating,  working,  and  in  all  the  gross 
functions  required. 

Concerning  transplanting  fat,  I  have  had  occasion  at 
subsequent  periods  to  open  areas  in  which  I  had  trans- 
planted fat  and  have  found  a  large  amount  of  fat  substance 
still  present,  and  this  I  have  assumed  to  be  the  fat 
originalh'  transplanted. 


Fig.   164. — Case  LI,   before  operation,   showing   full  amount  of  flexion  and 
extension.     Note  that  the  thumb  cannot  be  adducted  to  meet  any  of  the  fingers. 

Case  LI.  —  ^Nlr.  E.  History:  The  patient's  arm  was 
crushed  between  the  couplings  of  a  railroad  train.  Following 
this  a  severe  infection  ensued  in  the  hand  and  forearm  in 
which  apparently  both  the  ulnar  and  radial  bursae  were 
in\-olved  and  there  was  a  destruction  of  ner\'es  and  tissue  at 
the  time  of  injury  which  was  subsequently  followed  by 
sloughing  of  the  ulnar  nerve.  The  ultimate  result  presented 
at  the  time  he  came  under  my  observation,  tAvo  years  after 
the  injury,  was  that  of  a  claw-hand  with  sharp  flexion  at  the 
wrist  and  ankylosis  of  the  wrist-joint  with  adhesions  about 
the  tendons  and  scar  tissue  and  contracture  on  the  flexor 
surface  of  the  forearm. 


462 


SEQUELS  OF  INFECTIONS  OF  THE  HAND 


Operation. — The  scar  tissue  along  the  flexor  surface  was 
dissected  out,  the  ulnar  nerve  was  sought  for  and  could  not 
be  found,  as  it  had  l)een  lost  in  the  previous  destruction.  The 
median  nerve  was  isolated  from  the  scar  tissue  of  the  forearm, 
and  as  far  as  possible  the  tendons  were  removed  from  the  scar 
tissue.  Incision  was  made  on  the  dorsal  surface  on  the  radial 
side  and  the  carpal  bone  removed.  A  flap  of  fat  was  trans- 
planted from  the  leg  into  the  joint  and  the  wound  closed. 
Owing  to  scar-tissue  on  the  hack  and  buttocks,  it  was  deemed 
advisable  to  secure  skin  and  fat  for  the  restoration  of  the 


Fig.  165. — Case  LI,  two  months  after  operation.     The  flap  of  transplanted  skin 
can  be  seen  on  the  flexor  surface  of  the  forearm. 


flexor  surface  from  the  upper  portion  of  the  abdomen.  Here 
a  semilunar  flap  of  skin  and  subcutaneous  tissue  was  dissected 
out  with  its  base  downward.  The  fat  was  dissected  off  from 
the  flap  for  a  considerable  portion  of  its  surface.  The  skin 
was  then  attached  to  the  forearm  on  its  ulnar  side  and  the 
flap  of  fat,  still  attached  to  the  skin  at  its  base,  was  wrapped 
around  the  median  nerve  and  sutured  in  position.  By 
repeated  incisions  and  suturing  the  skin  flap  was  completely 
attached  at  the  end  of  twelve  days  and  the  hand  made  an 
immediate  recovery.  IHtimate  function  cannot  as  yet  be 
determined,  but  the  immediate  result  is  shown  by  the  picture. 


ATROPHY  AND  CONTRACTURE 


463 


The  patient  now  has  a  functionatinj;  hand  with  which  he  can 
feed  himself,  can  write,  adjust  his  tie,  drive  a  horse,  and  do 
other  gross  functions.  The  patient  is  entirely  satisfied  with 
the  result,  l)ut  I  am  sure  as  the  months  go  by  much  greater 
function  will  be  secured,  both  by  the  wrist,  which  now  has 
45  degrees  of  flexion  and  on  the  part  of  the  fingers,  which 
though  much  improved,  still  contract.  We  cannot  expect 
complete  restoration  of  function  owing  to  the  scar  tissue  in  the 
sheaths. 


Fig.  166. — Case  LI  I,  showing  full  amount  of  extension  and  flexion.     It  will  be 
noticed  that  these  fingers  were  atrophied  and  useless. 


Case  LLL— Wesley  Hospital,  No.  44,483  (Figs.  166,  167 
and  168).  'Age  twenty-six  years.  When  but  a  few  months  old 
the  patient  ha,d  a  severe  crushing  injury  of  the  hand  following 
which  she  apparently  suffered  from  an  extensive  sloughing 
and  infection.  On  examination  it  was  found  that  the  fingers 
were  flexed  into  the  palm,  she  was  unable  to  move  the  middle 
joints  at  all  and  unable  to  extend  the  proximal  phalanges 
more  than  to  a  right  angle  to  the  palm,  the  entire  range  of 


464  SEQUELS  OF  INFECTIONS  OF  THE  HAND 


/ 


Fig.  167. — Case  LI  I,  hand  inserted  in  the  flap. 


Fig.  168. — Case  LII,  showing  the  amount  of  function  present  at  the  end  of  one 

year  after  operation. 


ATROPHY  AND  CONTRACTURE  465 

motion  being  less  than  15  per  cent.  Tlie  hand  was  atrophied 
and  the  pahn  was  filled  with  scar  tissue.  Since  the  injury  had 
occurred  during  infancy  the  later  growth  of  the  arm  produced 
a  bizarre  contracture  making  the  hand  useless.  The  tendon 
sheath  of  the  thumb  had  apparently  not  been  involved  in  the 
process.  The  joints  of  the  thumb  were  fixed,  but  the  thumb 
as  a  whole  could  be  moved.  It  was  believed  that  the  patient 
had  an  old  infection  with  scar  tissue  binding  the  tendons  of 
the  fingers  into  the  palm  of  the  hand  and  that  if  anything 
could  be  promised  as  a  satisfactory  result,  this  entire  scar 
mass  would  have  to  be  removed.  Very  little  in  the  way  of 
result  was  promised  the  patient  owing  to  the  length  ot  the 
time  the  contracture  had  existed  and  the  atrophic  condition 
had  been  present. 

At  operation  the  findings  were  as  follows:  The  adhesions 
between  the  joint  surfaces  were  found  to  be  fibrous  and  not 
bony.  Some  motion  could  be  secured  under  anesthesia  by 
firm  passive  movements.  The  atrophy  of  the  fingers  was 
marked,  the  tendons  of  the  index,  middle,  ring,  and  little 
fingers  were  found  to  be  bound  firmly  in  the  scar  which 
iuA'olved  the  palmar  tissue  down  to  the  bone.  The  tendon 
sheath  of  the  little  finger  was  obliterated  and  the  tendon 
dissected  out  with  difficulty.  The  tendons  were  dissected 
free  and  the  fingers  were  straightened  out.  Great  care  was 
taken  in  dissecting  the  hands  to  preserve  the  blood  and  nerve 
supply.  A  flap  of  fat  and  skin  was  raised  from  the  buttocks 
through  which  the  hand  was  thrust,  the  flap  remaining 
attached  at  the  two  ends.  The  lower  edge  of  the  flap  was 
buttonholed  for  the  insertion  of  the  fingers.  Incisions  were 
made  upon  the  under  surface  through  the  fat  and  parallel  with 
the  tendons.  The  four  tendon  groups  were  then  inserted  into 
these  cuts,  attempt  made  to  separate  the  superficial  and  deep 
flexors,  and  the  fat  sutured  about  them  by  fine  catgut.  Pads 
of  vaseline  gauze  were  placed  under  the  back  of  the  hand  and 
the  flap  edges  sutured  to  the  hand  and  the  whole  held  to  the 
body  by  a.  plaster  cast.  At  the  end  of  ten  days  we  began  to 
cut  the  flap  from  its  attachment  to  the  body.  The  process 
was  completed  in  three  weeks  followed  subsequently  by  suture 
of  the  free  edges  of  the  flap  to  the  adjoining  hand  surface. 

The  result  obtained  from  a  cosmetic  standpoint  was 

fair.     From  a  functional  standpoint,  however,  the  patient 
30 


466 


sequeljE  of  infections  of  the  hand 


has  been  exceptionally  well  pleased  with  the  result.  She 
is  able  to  approximate  the  fingers  to  the  thumb,  can  grasp 
objects,  and  do  all  ordinary  work  for  which  a  hand  is 
intended.  Photographs  show  the  result  obtained.  The 
photographs  of  the  hand  before  the  operation  do  not  give 
an  adequate  impression  of  the  unfortunate  deformity. 


Fig.  169. — Case  LIII,  full  amount  of  flexion  and  extension  present, 
absolute  immobility  of  the  hand. 


Note  the 


Case  LIII. — Wesley  Hospital,  No.  43,733  (Figs.  169  and 
170).  The  patient  entered  the  hospital  complaining  that  he 
had  suffered  an  infection  in  the  hand  three  years'  previously, 
which  had  rendered  the  hand  absolutely  useless.  Upon 
examination  it  was  disclosed  that  he  had  had  an  infection 
which  originated  in  the  little  finger  and  had  undoubtedly 
involved  the  ulnar  and  radial  bursae.  Pus  had  ruptured  into 
the  palm  of  the  hand  and  into  the  forearm.  As  a  result  of 
this  the  fingers  were  held  absolutely  immobile  with  no  more 


ATROPHY  AND  CONTRACTURE 


467 


than  3  degrees  of  motion  in  any  direction.  The  nerves  were 
involved  and  the  hand  was  atrophied  and  absolutely  useless. 
The  patient  was  operated  upon  three  times.  At  the  first 
operation  the  bones  of  the  proximal  and  middle  rows  of  the 
carpal  joint  were  removed  and  a  pad  of  fat  was  inserted.  At 
the  second  operation  a  flap  of  fat  was  placed  under  and  over 
the  tendons  in  the  dorsum  of  the  hand  and  at  a  subsequent 
operation  a  flap  of  fat  was  placed  between  the  flexor  and 


Fig.  170.^Case  LIII,  result  after  one  year. 


deep  tendons  of  the  palm  and  between  the  skin  of  the  palm 
and  the  tendons.  An  infection  took  place  following  the  third 
operation  so  that  a  part  of  the  fat  sloughed  from  the  palm 
of  the  hand.  Flaps  of  fat  were  also  placed  about  the  tendons 
at  and  above  the  wrist-joirft.    These  apparently  remained. 

The  result,  while  not  perfect,  is  satisfactory  in  that 
the  patient  can  do  gross  things  such  as  holding  a  glass 
of  water,  removing  articles  from  his  pockets,  etc.,  but  it  is 


468 


SEQUELM  OF  INFECTIONS  OF  THE  HAND 


not  as  satisfactory  as  I  think  could  be  obtained  were  the 
operation  to  be  performed  with  my  later  experience. 
The  photographs  disclose  the  early  deformity  and  the 
result  one  year  after  operation. 

Case  LI\'. -Wesley   Hospital,    Fehlberg   (Hgs.    171,    172, 
and    173).     Ihis  patient  suffered  a  tendon-sheath  infection 


Fig.  171. — Case  LIV.     Note  the  contraction  and  immobility  of  the  fingers  and 
the  thumb  before  operation.     No  flexion  or  extension  possible. 

of  the  ulnar  and  radial  bursae  with  extension  into  the  palm, 
forearm,  and  wrist- joint.  He  first  entered  Cook  County 
Hospital  on  the  service  of  Dr.  Jacobs,  by  whom  he  was  referred 
to  the  author.  Infection  had  been  present  two  years  pre\ious 
to  his  entering  the  hospital.  Photographs  disclose  the  abso- 
lute immobility  of  the  hand  at  the  wrist-joint,  in  the  fingers, 


ATROPHY  AND  CONTRACTURE 


409 


and  in  tlic  thuinl).  1  he  hand  was  shrunken,  cohl,  and 
atrophic.  Four  operations  have  been  performed  upon  this 
hand  in  the  course  of  a  year  and  a  half.    At  the  first  operation 


Fig.  172. — Case  LIV,  after  third  operation,  showing  amount  of  flexion,  adduction 
of  the  thumb  and  fingers,  and  the  amount  of  extension. 


Fig.  173. — Case  LIV,  showing  the  result  after  the  third  operation. 


470  SEQUELS  OF  INFECTIONS  OF  THE  HAND 

the  proximal  row  of  carpal  bones  was  removed  at  the  wrist- 
joint  and  a  flap  of  fat  inserted.  Subsequent  experience  has 
taught  me  that  this  was  not  a  wise  procedure.  All  of  the 
bones  should  have  been  removed.  At  the  second  operation 
a  flap  of  fat  was  inserted  about  the  tendons  of  the  dorsum. 
At  the  third  operation  flaps  of  fat  were  placed  about  the 
tendons  on  the  flexor  surface  as  described  in  the  text. 

The  improvement  in  this  case  has  been  remarkable 
from  his  standpoint.  He  is  able  to  perform  all  the 
ordinary  functions  for  which  a  hand  is  needed,  but  it 
was  felt  that  a  better  result  could  be  secured  if  bones 
of  the  forearm  were  resected.  Consequently  a  fourth 
operation  was  performed  at  which  time  2.5  cm.  of  bone 
was  removed  from  the  lower  thirds  of  the  ulna  and  of  the 
radius.  The  maximum  amount  of  benefit  to  be  obtained 
from  this  operation  has  not  as  yet  been  secured.  Photo- 
graphs accompanying  disclose  the  amount  of  mobility 
secured  after  the  third  operation. 

Case  LV. — Wesley  Hospital,  No.  50,268  (Fig.  174).  This 
patient  suffered  a  lacerated  wound  of  the  forearm  in  which 
all  of  the  flexor  muscles,  the  median  and  ulnar  nerves  were 
severed,  and  an  extensive  infection  ensued  which  was  allowed 
to  heal  by  granulation.  One  year  after  the  injury  the  patient 
was  sent  to  me.  The  various  muscle  bodies  above  and  the 
tendons  below  were  dissected  out  and  united.  The  ulnar  and 
median  nerves  were  dissected  out  from  the  mass  of  scar  tissue. 
It  was  possible  to  join  the  ulnar  nerve  approximately  end  to 
end.  With  the  median  nerve,  however,  it  was  necessary  to 
bridge  an  inch  and  a  half.  This  was  done  by  running  silk 
from  the  upper  end  to  the  lower  end  through  a  fine  vein  which 
was  drawn  over  the  two  ends.  At  the  time  of  presentation, 
the  patient  had  an  absolutely  immobile  hand,  there  being  no 
motion  whatever  in  the  fingers  or  the  thumb.  This  was  due 
both  to  scar  tissue  and  to  the  fact  that  the  tendons  were  all 
cut.  After  suturing  the  muscles  and  nerves  as  above  described 
the  nerves  were  wrapped  individually  in  pads  of  fat  and  pads 
of  fat  were  placed  between  the  superficial  and  deep  muscles 
and  over  the  superficial  muscles. 


ATROPHY  AND  CONTRACTURE 


471 


A  report  was  received  from  this  patient  one  year  after 
operation.  The  photographs  show  the  function  present 
after  one  year.  Unfortunately  I  have  no  photograph  of 
the  hand  before  operation.     He  writes  me  that  he  is  able 


Fig.  174.— Case  LV,  result  one  year  after  operation. 

to  use  the  hand  now  in  his  work  as  a  farmer  without 
discomfort,  and  I  am  informed  by  his  physician  that 
sensation  is  returning  over  the  distribution  of  both  the 
ulnar  and  median  nerves,  the  latter  not  so  satisfactorily 


472  SEQUELM  OF  INFECTIONS  OF  rilK  HAND 

as  the  tormcr,  but  both  })atient  and  the  doctor  assure  nie 
that  sensation  here  is  improving.  The  result  should  be 
considered  satisfactory. 

I  had  one  other  case  with  much  the  same  findings  and  a 
similar  result. 

RfesuMi:. 

Necrosis  of  the  distal  phalanx  ordinarily  ends  in 
sloughing  of  the  diaphysis  alone.  Joint  function  should 
be  preserved.  Incision  should  be  made  laterally  instead 
of  upon  the  volar  surface.     (See  Chapter  I.) 

The  proximal  interphalangeal  joint  is  most  commonly 
involved.  The  proximal  phalanx  escapes  while  the 
epiphysis  and  part  of  the  diaphysis  of  the  middle  phalanx 
are  destroyed. 

Conservative  operations  may  be  done  with  some 
success. 

Isolated  involvement  of  the  tendon  sheaths  may  be 
present.  Incision  of  the  sheath  should  expose  all  involved 
parts. 

Chronic  palmar  abscesses  frequently  point  on  the 
dorsum,  passing  along  the  lumbrical  canals.  Palmar 
abscesses  may  be  opened  along  these  canals. 

Chronic  dorsal  abscesses  may  point  at  a  distance  from 
the  focus,  owing  to  the  dorsal  aponeurotic  sheet. 

The  carpal  joints  are  frequently  invaded  from  the 
radial  bursa;  abscesses  and  sinuses  appear  upon  the 
dorsum,  as  well  as  upon  the  flexor  surface.  It  will 
generally  be  necessary  in  these  cases  to  remove  all  of  the 
carpal  bones.     (See  Chapter  XXVII.) 

Serious  forearm  abscesses  lie  dorsal  to  the  flexor  pro- 
fundus digitorum,  and  should  be  opened  by  lateral 
drainage. 

Trophic  changes  result  from  the  tendency  of  the  pus  to 
extend  along  the  nerves  and  bloodvessels. 


SEQUELS  OF  INFECTIONS  OF  THE  HANI)  473 

Complete  function  can  l)e  i)romised  patients  suffering 
with  i)alniar  al)scesses  uncomplicated  by  tendon-sheath 
or  osseous  infection. 

Tendon-sheath  infections  operated  upon  early  give 
satisfactory  function. 

In  contractures  considerable  improvement  may  be 
secured  by  the  transplants  of  fat  about  tendons,  nerves, 
and  into  joints. 


CHAPTER  XXX. 

THE  RESTORATION  OF  FUNCTION  IN 
INFECTIONS  OF  THE  HAND. 

The  after-treatment  of  patients  suffering  from  injuries 
and  infections  of  the  hand  is  frequently  so  neglected,  or 
carried  out  in  such  a  haphazard  manner  that  the  ultimate 
results  fall  far  short  of  what  might  be  attained.  It  is 
not  sufficient  for  the  surgeon  to  save  the  life  of  a  patient 
suffering  from  a  virulent  hand  infection,  nor  to  assist  in 
controlling  the  infection  by  establishing  proper  and 
adequate  drainage;  unless  he  can  enable  his  patient  to 
return  to  his  former  occupation  with  a  complete  restora- 
tion of  function  he  has  failed  to  attain  the  ideal  result. 
This  ideal  is  not  a  hopeless  nor  a  fanciful  one.  It  can 
be  attained  in  the  majority  of  cases  by  the  help  of  exer- 
cise, massage,  hydrotherapy,  and  electrotherapy,  if  these 
agencies  are  employed  correctly  and  at  the  proper  time. 

The  primary  requisites  in  the  treatment  of  hand  infec- 
tions are  an  adequate  knowledge  of  the  anatomy  of  the 
hand,  of  the  underlying  pathological  process  present,  and 
of  the  proper  methods  of  surgical  treatment.  Of  equal 
importance  in  securing  a  perfect  result  is  a  comprehensive 
knowledge  of  the  various  methods  of  treatment  which  will 
bring  about  a  restoration  of  function  after  the  infection 
has  been  controlled. 

In  general  the  pathological  process  present  in  a  severe 
hand  infection  may  be  divided  into  three  stages:  first,  the 
stage  of  spreading  infection;  second,  the  stage  of  repair; 
and  third,  the  stage  of  fibrous  tissue  formation.  During 
the  first  stage  adequate  drainage  and  rest  are  the  essential 


RESTORATION  OF  FUNCTION  IN  INFECTIONS  OF  HAND  475 

factors;  during  the  second  period  gentle  passive  motion 
is  begun,  and  limited  active  exercises  are  added  as  soon 
as  the  infection  is  under  control;  by  the  time  the  third 
stage  is  reached,  gentle  but  frequently  repeated  exercises, 
both  active  and  passive,  should  be  well  under  way. 

It  is  difficult  to  lay  down  hard  and  fast  rules,  for  in 
every  case  the  treatment  depends  upon  the  location,  the 
extent,  and  character  of  the  infection.  The  first  step, 
obviously,  is  to  overcome  the  infection.  As  a  rule,  and  this 
is  of  particular  importance  in  infections  involving  tendon 
sheaths,  all  drainage  is  removed  at  the  end  of  forty-eight 
hours.  As  soon  as  possible,  usually  within  four  or  five 
days,  the  massive  hot  dressings,  which  encase  the  forearm 
and  most  of  the  arm,  are  replaced  by  an  arm  bath,  long 
enough  to  accommodate  the  hand  and  forearm,  and  deep 
enough  so  that  the  elbow  and  larger  part  of  the  arm  are 
immersed. 

This  may  be  used  continuously  or  during  three  or  four 
twenty-  to  thirty-minute  periods  during  the  twenty-four 
hours.  In  the  latter  case  the  hand  and  forearm  may  be 
exposed  to  the  light  of  an  arc  lamp,  or  of  a  cluster  of 
incandescent  bulbs  for  an  hour  or  longer  after  each 
immersion.  The  arm  bath  permits  the  passive  motion 
which  is  impossible  with  a  big  hot  pack,  and  makes  active 
movements  visible  to  the  patient  and  therefore  easier  of 
accomplishment. 

The  use  of  the  hot  pack,  hot  bath  and  electric  light  at 
this  stage  is  carried  out  with  the  idea  of  assisting  in  ever}' 
way  the/natural  forces  of  the  body  tissues  in  combating 
the  infection.  We  will  have  occasion  to  speak  of  them 
again  from  another  standpoint. 

Usually  within  seventy-two  hours  after  operation  gentle 
passive  motion  is  begun,  and  carried  out  for  a  few  moments 
at  the  daily  change  of  dressings.  The  patient  is  also 
encouraged  to  move  the  fingers  gently  by  his  own  muscu- 
lar contractions,  if  such  movements  are  not  painful.     As 


476  RESTORATION  OF  FUNCTION  IN  INFECTIONS  OF  HAND 

soon  as  the  arm  bath  is  substituted  for  the  hot  i)ack,  both 
passive  and  active  movements  are  carried  out  more 
extensively;  in  cases  in  which  the  infected  area  has  been 
drained  early,  gentle  passive  motion  may  be  carried  out  for 
fifteen-minute  periods  three  times  daily  after  the  fourth 
or  fifth  day,  preferably  while  the  hand  is  immersed  in  the 
bath.  The  importance  of  this  procedure  in  preventing 
permanent  stiffness  in  those  cases  in  which  the  tendon 
sheaths  are  involved  cannot  be  overestimated. 

The  best  guides  to  the  amount  of  exercise  that  may  be 
borne  with  safety  are  the  presence  or  absence  of  pain 
and  the  patient's  general  reaction,  as  evidenced  by  the 
temperature  and  pulse.  The  proper  degree  of  exercise 
should  not  be  painful.  The  patient  may  be  apprehensive 
at  first,  but  if  the  fingers  are  moved  gently  there  should  be 
no  actual  pain. 

If  the  temperature  rises  sharply  within  an  hour  after 
exercise,  one  must  limit  it  to  a  shorter  time  and  a  smaller 
range  of  movement.  Occasionally  the  reaction  to  a  viru- 
lent infection  is  so  great  that  a  very  limited  amount  of 
exercise  will  bring  about  a  sharp  temperature  reaction. 
In  such  cases  one  must  be  satisfied  with  preventing  adhe- 
sions, until  such  a  time  as  the  patient  has  developed  a 
greater  immunity  to  the  infection. 

By  the  time  healing  has  taken  place,  i.  e.,  by  the  end 
of  the  second  week  in  the  average  case,  exercises  supple- 
mented by  other  agencies  for  promoting  nutrition  and 
repair  of  the  tissues,  should  be  well  under  way. 

These  agencies  may  be  grouped  under  several  heads: 

1.  Hydrotherapy. 

2.  Electrotherapy. 

3.  Massage. 

4.  The  use  of  splints. 

5.  Exercise. 

6.  Occupational  therapy. 

7.  Psychotherapy. 


HYDROTHERAPY  ^11 

Some  of  them  require  the  use  of  a  considerable  amount 
of  apparatus,  some  depend  solely  on  individual  effort  and 
initiative.  They  all  have  one  object  in  view — restoration 
of  function  through  repair  of  diseased  tissues,  through 
increased  nutrition,  and  through  reeducation  of  muscle 
groups.  We  should  never  permit  ourselves  to  lose  sight 
of  this  object  in  the  contemplatation  of  new  or  fanciful 
names  or  of  elaborate  apparatus;  nor  attempt  to  make  one 
method  of  treatment  serve  in  every  case.  Rather  we 
should  try  to  discover  what  factors, — whether  muscle 
weakness,  adhesions,  joint  involvement,  nerve  involve- 
ment, or  scar  tissue  formation  with  diminished  blood 
supply, — are  chiefly  at  fault,  and  choose  the  line  of  treat- 
ment in  accordance  with  these  conditions. 

Hydrotherapy.  The  value  of  hydrotherapy  depends 
chiefly  upon  its  effect  on  the  bloodvessels.  By  immersing 
the  arm  in  a  hot  bath  the  capillaries  and  arterioles  are 
dilated,  the  part  becomes  hyperemic,  the  tissues  are 
softened  and  relaxed  to  such  an  extent  that  a  hand  that 
was  cold,  stiff  and  painful  may  become  capable  of  a 
considerable  degree  of  motion. 

If  the  inlet  jet  of  the  bath  is  set  at  an  angle  or  if  air 
under  pressure  is  forced  through  the  bath  the  beneficial 
effect  is  much  enhanced  by  the  "massage  action"  of  the 
swirling,  bubbling  water.  Such  devices,  known  as  the 
"whirlpool  baths"  or  the  "eau  courante"  of  the  French, 
were  largely  and  satisfactorily  used  throughout  the  war. 

Plunging  the  hand  and  forearm  alternately  into  baths 
at  a  temperature  of  i  io°  and  of  60°,  the  so-called  contrast 
baths,  are  of  value  by  reason  of  the  alternate  vasodilata- 
tion and  vasoconstriction  of  the  bloodvessels  produced  by 
the  varying  temperatures.  Such  a  procedure  improves 
the  vascular  tone  by  stimulating  the  smooth  muscle  of  the 
bloodvessels  themselves,  and  is  of  especial  value  in  cases 
with  considerable  scar-tissue  formation. 

The  douche  or  spray  may  be  used  in  a  similar  way. 


478  RESTORATION  OF  FUNCTION  IN  INFECTIONS  OF  HAND 

Electrotherapy.  Electrotherapy  is  available  in 
several  forms.  The  use  of  the  arc  light  and  of  clusters  of 
incandescent  bulbs  has  been  mentioned  as  a  part  of  the 
treatment  in  controlling  infection.  Like  moist  heat  the 
heat  of  an  electric  light  serves  to  produce  an  active 
hyperemia  that  is  the  most  important  factor  in  improv- 
ing nutrition.  The  beneficial  effect  of  light  as  well,  in 
destroying  organisms  and  stimulating  the  nutrition  of 
the  superficial  tissues,  needs  no  comment. 

The  galvanic  current  is  of  value  in  promoting  nutrition 
because  it  stimulates  muscle  contraction  and  increases 
the  vascular  flow  at  the  point  of  application,  and  because 
it  disperses  the  acid  products  of  metabolism.  Because 
of  the  repellant  property  of  the  positive  pole  for  metallic 
ions,  and  of  the  negative  pole  for  acid  ions  chemical 
substances  may  be  introduced  by  the  aid  of  the  galvanic 
current  directly  into  the  tissues. 

The  muscular  contraction  caused  by  a  galvanic  current 
occurs  only  at  the  making  or  breaking  of  the  current. 
For  this  reason  a  rather  complicated  apparatus,  including 
a  reversing  switch  and  metronome,  is  necessary  for  obtain- 
ing a  satisfactory  application  of  this  form  of  electrical 
stimulation,  and  this  fact  militates  against  its  general 
usefulness  under  ordinary  conditions. 

In  the  application  of  the  galvanic  current  an  area  of 
normal  skin  thoroughly  dry  is  chosen.  The  electrodes 
should  be  moistened,  applied  firmly,  and  should  not  touch 
each  other;  the  current  should  be  turned  on  slowly  and 
should  not  reach  a  point  which  causes  discomfort  or 
burning.  The  current  should  be  turned  off  slowly  at  the 
end  of  the  treatment.  The  application  of  the  positive 
pole  alleviates  pain,  and  that  of  the  negative  pole  stimu- 
lates the  circulation  in  old  scars. 

Ionization  is  said  to  be  of  especial  value  in  loosening 
adherent  scars  and  in  promoting  the  absorption  of  fluid 
in    injured   joints.     Ionization   with   chlorine   or   iodine 


MASSAGE  •  479 

ions  is  used   in   treating  scar   tissue,   and  with   sodium 
salicylate  in  treating  synovitis. 

The  more  useful  application  of  the  electric  current  is 
that  of  the  induced  or  faradic  current  in  producing  muscle 
contraction  by  stimulation  of  the  nerves  supplying  the 
muscles  in  question.  This  method  approaches  most 
nearly  the  normal  physiological  stimulation  of  the  muscle, 
and  so  is  of  particular  value  in  restoring  the  function  of 
wasted  and  atrophied  muscles.  The  treatment  of  joint 
and  muscle  injuries  with  the  faradic  current  may  be  begun 
as  soon  as  the  infection  is  under  control.  Since  the  point 
of  application  of  the  active  electrode  is  usually  fairly  high 
in  the  forearm  the  presence  of  open  incisions  in  the  palm 
and  lower  forearm  does  not  interfere  with  the  treatment. 

Bristow  has  devised  a  special  coil  by  which  the  strength 
of  the  current  may  be  graduated  by  slowly  pushing  in  or 
drawing  out  a  soft  iron  core  which  is  a  part  of  the  induction 
coil  itself.  He  believes  that  the  secret  of  restoration  of 
muscle  function  lies  in  the  graduation  of  the  contraction; 
that  one  should  begin  stimulation  with  the  minimum 
strength  of  current,  gradually  increasing  it  until  the 
maximum  strength  that  can  be  borne  without  pain  is 
reached,  and  then  as  gradually  decreasing  it.  He  empha- 
sizes the  fact  that  stimulation  should  never  be  painful, 
and  that  one  must  stop  before  the  muscle  becomes 
fatigued.  He  suggests  in  an  average  case  stimulating  the 
various  muscle  groups  four  or  five  times  for  a  minute  or 
two  in  turn  and  gradually  increasing  the  number  and 
duration  of  treatments  as  the  condition  improves.  There 
is  no  doubt  that  this  method  possesses  very  definite 
advantages,  particularly  because  it  is  possible  to  control 
definitely  the  strength  of  the  stimulus. 

Massage.  Massage  is  most  effective  if  preceded  by  a 
preliminary  preparation  of  the  part  by  hydrotherapy  or 
radiant  heat,  for  the  same  reason  that  a  coach  "warms 
his  men  up"  before  sending  them  into  an  athletic  contest. 


480  RESTORATION  OF  FUNCTION  IN  INFECTIONS  OF  HAND 

Aimless  rubbing  is  useless;  strong  and  rough,  or  weak 
and  timid  massage  produce  harmful  or  negative  results. 
In  the  words  of  Bucholz,  "Efficient  massage  reduces 
effusions,  softens  and  stretches  scar  tissue,  prevents 
atrophy  and  contractures  after  nerve  lesions,  stimulates 
the  circulation,  and  improves  the  general  nutrition  of  the 
part."  Its  early  use  along  with  passive  motion  is  import- 
ant in  the  production  of  a  functioning  hand,  particularly 
in  those  cases  where  infection  has  spread  upward  along 
the  forearm  and  involved  the  muscle  bellies  themselves. 

The  Use  of  Splints.  In  certain  neglected  cases,  or 
in  cases  with  contractures  of  long  standing,  the  use  of 
hydrotherapy  and  other  agencies  must  be  supplemented 
between  treatments  by  the  application  of  splints  in  order 
to  stretch  contracted  tendons  and  muscles  by  the  constant 
application  of  a  gradually  increasing  force,  and  to  relax 
muscles  which  have  become  weakened  through  prolonged 
over-stretching.  In  such  cases  unless  splints  are  applied 
after,  the  daily  treatments,  and  a  favorable  position  is  main- 
tained for  a  considerable  period  of  time  the  results  from 
other  methods  of  treatment  will  be  very  disappointing. 

The  most  frequent  example  of  injuries  of  this  type  is  the 
claw  contraction  of  the  hand  and  fingers  which  follows 
palmar  infections,  or  the  contracture  following  injuries 
involving  the  radial  (musculospiral)  nerve.  In  such  cases 
the  powerful  contractions  of  the  flexor  muscles,  augmented 
in  the  one  case  by  scar  tissue  formation,  and  in  the  other 
by  the  paralysis  of  the  extensors,  will  result  in  a  serious 
and  permanent  deformity  unless  the  muscles  be  gradually 
stretched  by  the  constant  use  of  appropriate  splints. 

With  these  cases  it  is  our  practice  to  stretch  the  con- 
tracted muscles  as  far  as  possible  under  an  anesthetic, 
and  then  to  bind  the  hand  and  forearm  to  a  moulded 
plaster-of- Paris  splint.  The  splint  is  removed  for  massage 
and  electrical  treatment,  but  reapplied  immediately  when 
treatment  is  concluded. 


EXERCISE  481 

By  gradually  straightening  the  splint,  and  finally 
substituting  a  hyperextension  or  "cock-up"  splint  for 
the  straight  splint,  it  is  often  possible  to  bring  about  a 
considerable  restoration  of  function  in  individuals  in 
whom  the  deformity  has  already  become  marked. 

Exercise.  Exercise  of  injured  tendons  and  muscles 
may  be  passive  or  active.  Passive  exercises  may  very 
well  be  carried  out  in  conjunction  with  massage.  They 
help  to  stretch  contractures,  to  increase  the  range  of 
motion  in  stiffened  joints,  to  reeducate  the  muscles  in 
performing  normal  movements.  Such  exercises  should 
be  carried  out  slowly  and  gently;  never  with  quick,  jerky 
movements.  They  should  be  preceded  by  the  application 
of  heat. 

Twenty-four  hours  after  the  breaking  down  of  joint 
adhesions  passive  motion  should  be  carried  out  by  moving 
the  limb  at  least  once  through  its  complete  range  of 
motion.  These  movements  should  be  repeated  each  day 
and  the  part  kept  at  rest  between  treatments.  After 
stretching  painful  scars  or  contracted  muscles  and  tendons 
massage  may  be  carried  out  in  about  twelve  hours,  and 
followed  by  exercises,  both  passive  and  active. 

In  treating  the  later  results  of  injury  or  infection,  where 
the  main  object  is  to  reeducate  or  restore  wasted  and 
atrophied  muscles,  active  exercises,  either  voluntary  or 
against  resistance,  constitute  the  ideal  method. 

These  may  be  introduced  in  a  number  of  ways:  as 
voluntary  exercises  for  the  interested,  intelligent  patient; 
with  the  assistance  of  apparatus  especially  adapted  to 
develop  .particular  groups  of  muscles;  as  games  of  various 
sorts;  and  through  the  adaptation  of  tools  which  will 
permit  the  patient  to  work  at  some  particular  trade  at  the 
same  time  that  he  is  reeducating  the  weakened  muscles. 

In  practically  any  case  of  joint  or  muscle  injury  passive 
motion  of*  the  injured  part  with  the  help  of  the  sound 
member,  combined  with  voluntary  exercises  carried  out 

31 


482  RESTORATION  OF  FUNCTION  IN  INFECTIONS  OF  HAND 

at  the  eeirliest  moment,  will  do  much  toward  restoring 
function  if  the  patient  has  sufficient  intelligence,  energy 
and  will-power.  Unfortunately  most  of  us  require  other 
stimuli. 

Many  different  and  ingenious  devices  have  been  sug- 
gested for  supplying  the  necesssary  stimulus.  Fig.  175 
illustrates  devices  for  exercising  and  stretching  the  flexor 
tendons   of   the    fingers,    for   promoting   abduction   and 


I  ■CrWQK^TMi^dVBBTiaaM'^^  JfWHK^^.VM-« 


Fig.  175. — Table  with  various  devices  for  exercisiiii^  ilu    hnuls  and  fingers. 

adduction  of  the  fingers,  for  stretching  scar-tissue  between 
the  fingers,  and  for  developing  various  other  functions  of 
the  hand  and  wrist. 

Fig.  176  illustrates  a  device  for  exercising  the  flexors  and 
extensors  of  the  hand.  The  wrist  and  forearm  are  strap- 
ped down,  the  fingers  inserted  into  the  glove  tips,  and 
weights  added  until  the  patient  can  just  lift  them.  As 
function  improves  heavier  weights  may  be  substituted. 
A  special  attachment  serves  for  exercising  the  thumb. 


EXERCISE 


483 


Fig.  177  illustnites  the  roller  for  exercising  the  flexors 
and  extensors  of  the  hand  and  wrist.  By  winding  up  the 
cord  supporting  the  weight,  first  in  one  direction  and  then 
in  the  other,  the  flexors  and  extensors  may  be  exercised 
in  turn.  In  exceptionally  bad  cases  the  roi)e  and  weight 
are  replaced  by  a  pendulum  which  is  set  swinging  in  an 


Fig.  176. — Home-made  device  for  exercising  the  fingers  and  thumb. 

arc  of  6o°rthis  causes  the  roller  to  move  back  and  forth, 
and  thus  to  favor  flexion  and  extension  of  the  fingers. 
This  passive  exercise  is  supplemented  by  active  move- 
ments as  soon  as  the  patient  can  grasp  the  roller.  In 
such  cases  it  is  usually  necessary  to  attach  finger  cuffs  to 
the  cylinders  to  help  hold  the  hand  and  fingers  in  close 
apposition  to  the  roller  while  it  is  in  motion. 


484  RESTORATION  OF  FUNCTION  IN  INFECTIONS  OF  HAND 

The  apparatus  modified  from  Flint  and  others  with  its 
pendulum  attachment  (Figs.  175  and  177)  serves  a  similar 
purpose.  The  fingers  are  slipped  into  the  glove  on  the 
trap  door  in  the  table  top,  and  by  flexing  the  fingers  the 
pendulum  is  moved  back  and  forth,  so  as  to  cause  flexion 
and  extension  at  the  joints  of  the  hand  and  at  the  wrist.  A 


Fig.  177. — Home-made  mechanical   devices  for  exercising  the  fingers  and  wrist. 

device  for  assisting  in  rotating  the  fingers  may  be  attached. 
A  solid  wheel  with  holes  the  size  of  the  fingers,  at  various 
distances  from  its  axis,  is  fitted  with  an  axle  supporting  a 
weight  at  the  end  of  a  cord.  The  hand  is  fixed,  the  finger 
inserted  first  in  the  hole  nearest  the  center,  and  the  weight 
is  wound  up  (Fig.  175).  As  rotation  is  improved  the  more 
distant  holes  are  used. 


EXERCISE 


485 


In  all  these  exercises  the  principle  of  competition  and  of 
comparison  is  of  tremendous  importance.  Every  form  of 
apparatus  should  be  devised  so  that  it  is  possible  to 
determine  definitely  the  amount  of  improvement  from  day 
to  day — in  the  increased  weight  moved  or  raised,  in  the 
increased  angle  of  flexion  or  extension  at  any  particular 
joint,  or  in  increased  motor  power. 

For  this  purpose  a  protractor  for  measuring  the  range  of 
motion  at  any  particular  joint  is  of  great  value.   Figs.  178, 


Fig.  178. — Protractor  (modified  from  Elder  and  others)  for  measuring  the  range 
of  motion  of  various  phalanges. 

179,  180,  181,  182,  183,  184  and  185  illustrate  such 
devices  for  measuring  the  degree  of  flexion  or  extension  of 
the  fingers.  Similar  devices  may  be  used  for  measuring 
the  range  of  motion  at  the,  wrist,  elbow,  and  shoulder. 
The  grip  may  be  measured  by  squeezing  the  partially 
inflated  cuff  of  a  blood-pressure  apparatus. 

Games  are  of  particular  value  in  bringing  about  uncon- 
scious and  effortless  exercise  of  injured  muscles.  Where 
a  considerable  number  of  patients  with  somewhat  similar 
disabilities  are  grouped  together,  competitive  games  offer 


486  RESTORAriON  OF  FUXCTIOX  IN  INFECTIONS  OF  HAND 


the  happiest  and  simi)lest  soUition  of  the  i)rol)lein  of  find- 
ing   the    necessary    stimukis.     Very    sim])le    games    wil 


often  serve  the  purpose.  The  sick  man  not  infrequently 
is  absolutely  happy  with  amusements  that  would  bore 
him  tremendously  under  different  circumstances. 


EXERCISE 


4S7 


For  exercising  the  muscles  controlling  finger  movements, 
playing  marbles  or  crokinole,  piano-playing,  or  practising 
on  a  typewriter  are  of  ])articular  value.  For  exercising 
the  joints  of  the  hand  and  wrist  hand  ball,  Indian  clubs, 
dumb  bells,  bowling,  quoits,  and  billiards  are  particularly 
hel])ful.    A  glove  with  straps  attached  to  the  dorsum  of  the 


Fig.  180. — Devices  for  keeping  the  patient  interested  in  using  the  hand. 


wrist,  running  over  the  finger  tips,  and  buckled  to  the 
palmar  surface  of  the  wrist  is  a  useful  and  valuable  aid  in 
permitting  patients  with  stiff  fingers  to  take  part  in  various 
games.  The  fingers  may  be  flexed  as  far  as  possible  about 
a  baseball  bat,  a  golf  club,  or  a  tennis  racquet.  If  neces- 
sary, the  handle  of  the  club  may  be  enlarged  to  permit  of 
its  being  grasped  more  readily.     With  the  aid  of  "grips" 


488  RESTORATION  OF  FUNCTION  IN  INFECTIONS  OF  HAND 

in  such  a  glove  patients  may  box  or  punch  a  bag  to  their 
hearts'  content.     Other  games  and  forms  of  exercise  for 


Fig.  181. — Glove  with  straps  attached  to  flex  stiffened  fingers. 


Fig.  KS2.--\  arious  devices  for  holding  the  patient's  interest  and 
developing  function. 


OCCUPATIONAL  THERAPY 


489 


training  special  muscle  groups  or  for  general  development 
will  readily  suggest  themselves.  Much  depends  on  the 
enthusiasm  and  initiative  of  the  one  directing  the  treat- 
ment. 

Occupational    Therapy.     Another    interesting    and 
important  method  in  reeducating  maimed  and  disabled 


Fig.  183. — Use  of  the  punching  bag  for  exercising  contracted  fingers. 


individuals  is  in  training  the  injured  member  in  the  use 
of  the  implements  and  tools  of  various  trades  and  crafts. 
So-called  "occupational  therapy"  was  used  with  ever- 
increasing  success  through  the  later  years  of  the  war, 
particularly  under  the  stimulating  influence  of  Sir  Robert 
Jones  throughout  the  orthopedic  hospitals  of  England,  and 
later  in  our  own  army  hospitals  in  the  United  States. 


490  RESTORATION  OP  FUNCTION  IN  INFECTIONS  OF  HAND 

The  recognition  of  the  fact  that  the  mind  of  a  sick  man 
needed  treatment  as  well  as  his  body,  and  that  the  most 
successful  mental  treatment  lay  in  helping  him  to  achieve 
something  definite — the  making  of  a  table,  the  setting-up 
of  type,  the  repair  of  a  motor — brought  about  a  radical 


Fig.  184.— Playing  the  piano  is  an  especially  good  exercise  for  those  of   musical 

inclinations. 

change  in  the  methods  of  treating  wounded  men  during 
the  long  stages  of  convalescence. 

The  same  factors— the  stimulating  mental  effect  of 
useful  work,  the  hopefulness  for  the  future  that  comes  to 
an  injured  man  in  the  realization  that  he  is  fitting  himself 
for  a  new  occupation  perhaps  more  desirable  than  the  one 


OCC  UPA  TIOX.  I L  Til  ER.  I P  V 


491 


he  is  forced  to  reliiKiuish,  the  diversion  of  interest  from 
himself  and  his  troubles  into  other  channels — are  just  as 
important  in  the  after-treatment  of  the  injured  patient 
in  ci\'il  life  as  in  military  life. 

In  reeducating  the  wounded  at  the  various  reconstruc- 
tion hospitals  throughout  the  United  States  practically 
every  mechanical  trade  was  utilized.  Typewriting,  type- 
setting, carpenter  work,  cabinet  making,  blacksmithing, 
modeling  and  weaving  were  only  a  few  of  the  trades  that 
proved  of  especial  value  for  indixiduals  with  injured 
hands  and  forearms. 


Fig.  '85. — The  use  of  the  typewriter  often  holds  the  interest  and  is  a  valuable 

exercise. 

Major  H.  R.  Allen  suggested  the  use  of  modeling 
material,  such  as  is  used  by  artists  and  dentists,  for 
adapting  particular  tools  to  the  use  of  injured  men. 
"This  material  becomes  thoroughly  soft  and  plastic 
without  melting  when  placed  in  hot  water  for  a  few 
minutes;  then  if  it  is  plunged  into  ice  water  it  hardens 
like  glass.  This  process  ma>-  be  repeated  as  often  as 
desired  with  the  same  material.  The  material  is  applied 
to  the  handle  of  the  hammer,  saw,  chisel,  axe,  or  tool 


492  RESTORATION  OF  FUNCTION  IN  INFECTIONS  OF  HAND 

desired  and  while  soft  the  maimed  hand  of  the  patient 
grasps  it,  closing  to  its  maximum  in  the  i)lastic  material. 
Then  the  tool  is  released  and  the  handle  plunged  into 
ice  cold  water,  which  sets  the  mold.  The  patient  finds 
that  in  this  manner  he  can  use  the  tool  with  the  injured 
hand.  As  function  improves  the  mould  is  reset  by 
plunging  the  handle  into  hot  water,  remoulding  and 
resetting.  As  the  end-result  approaches,  the  amount  of 
modeling  material  becomes  less  and  less  until  finally  there 
is  little  or  none  left  on  the  handles  of  the  tools." 

Psychotherapy.  In  every  case  the  result  attained 
will  depend  ultimately  upon  the  energy,  enthusiasm  and 
judgment  that  the  surgeon  brings  to  his  task. 

The  most  surly  or  obstinate  patient  will  respond  eventu- 
ally to  optimism  and  encouragement  if  he  realizes  the 
possibilities  of  patience  and  perseverance.  Enthusiasm  is 
infectious;  and  with  these  cases  the  surgeon  must  usually 
furnish  the  greater  share.  This  will  not  be  dif^cult  if  he 
has  the  faith  that  comes  with  past  performance. 


INDEX. 


Abscess,  collar-button,  55 
treatment  of,  57 
in  course  of  lymphatic  vessel,  314 
deep,  of  forearm,  397 
distal  palmar,  55 

fascial-space,     after-treatment     of, 
290 
treatment  of,  277 
of  forearm,  treatment  of,  416 
localized,  57 

hypothenar  space,  57 
thenar  space,  57 
location  of,  in  forearm,  398 
of  middle  palmar  space,  treatment 

of,  277 
periglandular,  treatment  of,  356 
of  radial  lymphatics,  171 
shirt-stud,  55 
subaponeurotic    space,     treatment 

of,  289 
subclavicular  and-  shoulder,  treat- 
ment of,  356 
subcutaneous,  in  forearm,  396 

treatment  of,  in  lymphangitis, 
355 
subepithelial,  39 
thenar  space,  treatment  of,  287 
Absorption  of  virulent  toxins,  preven- 
tion of,  248 
Adhesions,  prevention  of,  290 
in  tenosynovitis,   199 

prevention  of,  274 
treatment  of,   Bier's,   272 
Alcohol  dressings,  246 
Anatomv,  cross-section,  distal  to  \veh, 
85 
of  forearm,  148 

nine     centimeters     above 

radial  styloid,  150 
_in   relation   to   infections, 
^^      147 
seven    centimeters    above 

radial  styloid,  148 
three    centimeters    above 
radial  styloid,  148 
one-half    centimeter    proximal 

to  the  joint,  88 
taken  at  wrist,  95 
three  centimeters  above  joint, 

90 
through  base  of  palm,  93 


Anatomy,  cross-section,  through  distal 
part    of     thenar     emi- 
nence, 92 
epiphysis  of  proximal  pha- 
lanx, 86 
two  centimeters  above  joint,  88 
of  hand  and  forearm,  81 
of  hypothenar  space,  94 
of  lymphatics,  296 
of  middle  palmar  space,  90 
of  thenar  space,  91 
Anesthesia  in  operations,  247 
Annular  ligament  cut  in  hand  infections, 
249,  258,  266 
extensions  of  pus  matter,  172 
Anthrax,  392 
Arthritis,  426 

metacarpo-phalangeal,  182 
Atrophy,  426,  448 

Axillary-  glands,  source  of  involvement, 
315  ' 

B 

Bacteria,    influence    of    types    of,    in 

lymphangitis,  310 
Baking  in  dn,',  hot  air,  79 
Bier's    hvperemic   treatment,    72,    232, 
248,  272,  348  ' 
treatment  of  adhesions,  274 
Bloodless  field  in  operations,  247 
Bone  involvement,  430 
Bones    of    finger,    treatment    of,    when 
involved,  436 
of  wrist-joint,  necrosis  of,  422 
Bursitis,  radial,  diagnosis  of,  218 


Carbolic  acid  gangrene,  245 
Carbuncles,  41 

anatomical  considerations  of,  41 

pathogenesis  of,  41 

pathology-  of,  41 

site  of,  41 

treatment  of,  45 
Carpals,  involvement  and  treatment  of, 

437 
Cauter^-  to  open  abscesses,  78 
Classic  gaseous  gangrene,  387 
Claw  hand,  203 

Collar-button  abscess,  treatment  of,  55 
Contractures,  426,  448 
Cross-sections    of    hand    and    forearm. 
See  Anatomj'. 


494 


INDEX 


Devices  for  exercising  hands  and  fingers, 

482,  483,  484,  487 
Distal   palmar  abscess,   55 
Diverticula  of  each  of  definite  space,  1 14 
Dorsal  abscess,  diagnosis  of,  222 

as  extension  from  thenar 

space  infection,   177 
from    middle   palmar   ab- 
scess, 175 
subaponeurotic  space,  98 

experimental  study  of 
boundaries  and  posi- 
tion of  secondary  ab- 
scesses in  case  of  rup- 
ture from,  139 
subcutaneous  spaces,  98 

boundaries,       diverticula, 
and     position     of     sec- 
ondary abscess  in  case 
of  rupture  from,   145 
experimental      study      of 
boundaries  and  position 
of  secondary  abscess  in 
case    of    rupture    from, 
138 
Dorsum  of  hand  and  forearm,  lymphan- 
gitis and,   316 
infections  beginning  in,  193 
tendon  sheaths  of,  1 10 

infection  of,  treatment  of, 
271 
Drainage  in  incisions  in  forearm,  259 
in  infections,  77 
in  palmar  abscess,  278 
in  tenosynovitis,  248,  272 
at  wrist,  258 
Dressing,  alcohol,  246 

dry,  in  tenosynovitis,  273 

hot,  moist,  in  lymphangitis,  346 

in  tenosynovitis,  245,  272 
Drugs,    antagonistic,    in    lymphangitis, 

351 
Durillon  force,  308 

E 

Economic  treatment  of  infections  of  the 

hand,  365 
Edema  of  dorsum,  differentiated  from 
erysipelas,  315 
mistaken  for  pus,   176 
in  tenosynovitis,  203 
Electrotherapy  in  restoration  of  func- 
tion, 478 
Embryology  of  hand,  comparative,  141 
Epitrochlear  glands,  source  of  involve- 
ment, 314 
ErySjipelas,  384 

differentiated  from  edema  of  dorsum, 
314 
from  lymphangitis,  328 


Erysipelas,  gangrenous,   384 

treatment  of,  384 
Erysipeloid,   385 
Esmarch  bandage,  247 
Excretion,  stimulation  of,  in  infections, 

79 

Exercise  in  restoration  of  function,  481 

Extensor    carpi    radialis    longior    and 

brevior,    tendon    sheath    of, 

110 

ulnaris,  tendon  sheath  of,  111 

communis  digitorum,  tendon  sheath 

of,  112 
indicis,  tendon  sheath  of,  112 
longus   pollicis,   tendon   sheath   of, 

111 
minimi  digiti,  tendon  sheath  of,  112 
ossis     metacarpi     pollicis,     tendon 
sheath  of,   110 


Factory  prophylaxis,  71,  365 
Fascia  palmaris,  abscess  of,  acute,  prog- 
nosis and  resume  of,  291 
after-treatment  in,  289 
diagnosis  of,  215 
pathogenesis  of,  159 
pathology  of,  197,  199 
surgical  considerations  of, 

159 
svmptoms    and    signs    of, 
"  201 
treatment  of,  276 

immobilization  in, 2 10 
experiments  as  to  boundaries, 
div^erticula,    and    extensions 
from,    138 
isolated  necrosis  of,  203 
Fascial  spaces,  extension  of,  from  one 
to  another,   171 
of    forearm,    experimental    in- 
jection of,  152 
infection  of,  65 

direct  implantation  of  in- 
fection in  spaces,  165 
etiology  of,   159 
relation   to   lymphangitis, 
169,  295 
involvement  of,  164 

recapitulation  as  to  source 
of,  178 
normal  boundaries  of,  126 
position  of  secondary  abscess 

in,  126 
relation  of,  to  synovial  sheaths, 
113 
to  tendon  sheaths,  125 
study  of,   by  serial   cross-sec- 
tions, 84 
Fat,  transplantation  of  flaps  of,  461 
Felons,  25 

after-treatment  of,  31 


INDEX 


495 


Felons,  etiology  of,  25 
pathogenesis  of,  25 
pathology  of,  26 
treatment  of,  2*) 
Finger,  index, diagnosis  of  extension  from 
infections  beginning  in,  209 
experimental   study   of  exten- 
sion    after     rupture     from 
tendon  sheath  of,   123 
infection  involving,  180 
tendon  sheath  of,  101 

extensions  from  infec- 
tions in,  183 
relation  of,  to  thenar 
space,  101 
teno9vnovitis  of,  treatment  of, 
248 
infectious  processes  of,  427 

course  of  lymphatic  from 

each,  314 
extensions    from    primary 

foci  on,  180 
involving  sides  of,    170 
involvement  of,  432 
little,  diagnosis  of  extensions  from 
infections  beginning  in,  192, 
204 
experimental   study   of   exten- 
sion    after     rupture     from 
tendon  sheath  of,   119 
infection  of,  incision  in,  252 
tendon  sheath  of,   102 

relation  of,  to  middle 
palmar  space,  102 
tenosynovitis  of,  treatment  of, 

252 
ulnar    bursa    and,    extensions 
from,  treatment  of,  259 
middle,  diagnosis  of  extension  from 
infections  beginning  in,  189, 
209 
experimental   study   of   exten- 
sion after  rupture  from  ten- 
don sheath  of,  116 
extensions  from  tenosynovitis 

of,  treatment  of,  251 
tendon  sheath  of,  101 

relation  of,  to  middle 
palmar  space,  102 
ring,  diagnosis  of  extensions  from 
infections  beginning  in,  191, 
210- 
experimental   study   of  exten- 
sion after  rupture  from  ten- 
don  sheath   of,    117 
extensions  from   tenosynovitis 

of,  treatment  of,  252 
tendon  sheath  of,   101 

extensions  of,  191 
relation  of,  to  middle 
palmar  space,    102 
Flexor  longus  pollicis,  tendon  sheath  of, 
103 


F"lexor  longus  pollicis,  tenosynovitis  of, 

213 
Forearm,  abscess  of,  deep,  397 
diagnosis  of,  22^ 
subcutaneous,  396 
treatment  of,  416 
anatomy  of,  80 

in  relation  to  infections,  147 
dissection  and  experimental  injec- 
tions of,  157 
incisions  in,  drainage  in,  259 
infections  of,  treatment  of,  259 
injections  of  fascial  spaces  of,  152 
involvement  of,  abscess  formation 
without  complications,  398 
associated  with  wrist-joint  in- 
vasion, 404 
following      tenosynovitis       of 

thumb,  treatment  of,  261 
from  infections  of  hand,  path- 
ology and  diagnosis  of,  396 
from    middle    palmar     space, 

171 
from  ulnar  bursitis,  treatment 

of,   255 
incision  in,  358 

secondarv     hemorrhage     and, 
412 
treatment  of,  416 
to   little    finger   infection, 
204,   207 
lymphatics  of,  396 
serial  cross-section  of,.  148 
Forssell,  22S,  229 
Friedrich,    238 
Frog  felon,  55 

Function    of    hand,    restoration    of,    in 
infection,  474 


Gangrene,  carbolic  acid,  245 
gaseous,  classic,  387 

mixed,  388 

toxic,  388 
Gangrenous  erysipelas,  384 
Gas-bacillus  infection,  386 
Gaseous  gangrene,  classic,  387 

mixed,  388 

toxic,  388 
Gauze  in  treatment  of  infections,  77 
Gonorrheal  tenosynovitis,  224 
Gutta-percha  in  treatment  of  infections, 
■    77 

H 

Hand,  anatomy  of,  80 

chronic  processes  in  palm  of,  treat- 
ment of,  437 

forearm  and,  Ivmphatic  vessels  of, 
298 

infections,  diagnosis  of,  difterential, 
224 

restoration  of  function  of,  474 


496 


INDEX 


Hand,   restoration  of  function  of,  elec- 
trotherapy in,  478 
exercise  in,  481 
hydrotherapy  in,  477 
massage   in,   479 
occupational    therapy    in, 

489 
psychotherapy  in,  492 
splints  in,  489 
Heineke,  233 
Helferich,  240 
Hemolysis   in   streptococcus   infections, 

310 
Hemorrhage    in    forearm    involvement, 
412 
secondary,  treatment  of,  261,  394 
Hot  air,  baking  in  dry,  79 
Hydrotherapy   in   restoration   of   func- 
tion, 477 
Hyperemic  treatment,  Bier's,   72,  232, 

248,  272,  348 
Hypothenar  space,  94,  98,  232 

abscess  of,  treatment  of,  276 
anatomy  of,  94 

boundaries,     diverticula,     and 
position  of  secondary  abscess 
in  case  of  rupture  from,  145 
experimental  study  of  bound- 
aries, diverticula,  and  posi- 
tion of  secondary  abscesses 
in  cases  of  rupture  from,  141 
infection  of,  diagnosis  of,  222 
relation  of,  to  infection  in 
middle    palmar    space, 
175 
involvement  of,  source  of,  178 


Immobilization    in    fascial-space    ab- 
scesses, 290 
in  tenosynovitis,  273 
Incision  in  forearm  involvement,  256 
errors  in  making,  255 
in  infections,  prophylactic,  76 
in  little  finger  infections,  252 
in  lymphangitis,  349 
in  tenosynovitis,  248 
in  ulnar  bursal  infections,  252 
Index  finger.     See  Finger,  index. 
Industrial  pursuits  and  infection,  365 
Infections.       See    also     Tenosynovitis, 
Lymphangitis,   Fascial-space  in- 
fection, 
carbuncular,  41 
chronic,  repeated,  357 
staphylococcus,  51 
classification  of,  17 
diagnosis  of,  general,  59 
drainage  in,  77 
grave,   59 

passive  hyperemia  in,  72 
simple  localized,  25 


Infections,  spread  of,    from   any   given 
primary  focus,  181 
from     one     fascial     space     to 

another,  171 
from  sides  of  fingers,  171 
subepithelial,  39 
treatment  of.  Bier's,  72 

boric  acid  solution  in,  73 
cautery  to  open  abscesses  in, 

78 
drainage  in,  77 
drugs  in,  72 
gauze  in,  77 
general  principles  of,  71 
gutta-percha  in,  77 
hot,  moist  dressings  in,  73 
Klapp  suction  cup  in,  73 
massage  in,  79 
passive  hyperemia  in,  72 
prophylactic  incision  in,  76 
rest   in,   71 
rubber  tubes  in,  77 
types  of,  17 
Intermediary   palmar  sheath,  anterior, 
108 
posterior,  108 
Interosseous  artery,  anterior,  lymphatic 

abscesses  and,   171 
Interphalangeal    joint,    proximal,    rela- 
tion of,  to  tendon  sheath,  101 
Iodine  in  prophylaxis,  71,  372 


Joints,  interphalangeal,  211 

proximal,  treatment  of,  when 
involved,  434 
involved  secondary  to  little  finger 

infection,   204 
metacarpo-phalangeal,  involvement 

and  treatment  of,  436 
preserving    function    of,    in    teno- 
synovitis, 274 


Karewski,  228 
Kausch,  228 
Klapp,  73,  227,  447 
Konig,  237 


Lacunae  of.  lymphatics,  relation  of,  to 
subcutaneous  abscess,  314,  350 

Lejars,  239 

Leukocytosis,  increase  of,  in  lymphan- 
gitis, 353 

Lexer,  237 

Little  finger.     See  Finger,  little. 

Lumbrical  muscles,  extension  to  the- 
nar space  from  middle  palmar  space, 
175 


INDEX 


497 


Limilnical  muscles,  involved  from  infec- 
tion      of       middle 
finger,  18<),  210 
of  tendon  sheath,  163, 

183,  209 
in  web,  191 
from  middle  palmar  space, 

171 
from    ring    finger    tendon 

sheath,  191,  209 
secondary  to  index  teno- 
synovitis,       treat- 
ment of,  250 
to  little  finger  infec- 
tion, 208 
involvement  of,  source  of,  171 
relations   of,    to   infections   of 
middle   palmar  space,    101, 
167,  250 
tenosynovitis  and,  249 
Lymphangitis,  60 

acute,  simple,  326 

with     minor    local     complica- 
tions, 325 
with    serious    local    complica- 
tions, 326 
with     systemic     involvement, 
329 
bacteria  and,  310 
in  central  part  of  palm,  193 
complications  of,  treatment  of,  355 
deep,  330 

differentiated  from  erysipelas,  328 
dressing  in,  346 
drugs  in,  antagonistic,  351 
etiology  of,  308,  319 
extension  of,  in  infection  of  middle 
finger,  189 
of  thumb,  188 
frequenc\-  of  localization  in,  328 
hot,  moist  dressings  in,  354 
incisions  in,  349 
leukocytosis  in,  increases  of,  353 
pathogenesis  of,  308,  320 
pathology  of,  308,  320 
phlegmonous,  328 
prognosis  of,  342 

relation  of,   to   fascial-space  infec- 
tion, 295 
to  other  types  of  infection,  295 
to  tenosynovitis,  295 
septicemia  and,  296 
symptoms  and  signs  of,  324 
systemic  involvement  from,  332 
treatment  of,  346 

normal  salt  solution  in,  351 
peptonized  food  in,  351 
types  of,  295,  325 
Lymphatic  abscess  along  arteries,  171 
experimental     injections    and, 
318 
dilatations,  sacciform,  297 
infections,  treatment  of,  346 

32 


Lymphatic     infections,     treatment    of, 

rest  in,  348 
Lymi)hatics,  anatomy  of,  296,  298 

influence  of,  on  course  of  infec- 
tion, 313 
course  of,  170 

deep,  305,  316 
fascial-space  infection  and,   169 
history  of,  18 

relation  of  tendon  sheaths,  315 
superficial,  298 
termination  of,  305 

M 

Mascagni,  296 

Massage  in  restoration  of  function,  479 

in  treatment  of  infections,  79 
Mauclaire,  238 

Median  nerve,  relation  of,  to  bursie,  106 
Metacarpal   bones,   extension   of  infec- 
tion of,  to  dorsum,  175 
fifth,  relation  of,  to  infection 

of  hypothenar  space,  168 
involvement  and  treatment  of, 

436 
of  middle  finger,  189 
osteomyelitis  of,  191,  192 
relation    of,    to    infections    of 
middle  palmar  space,  168 
Metacarpo-phalangeal  arthritis,  182 

joint  and  the  tendon  sheath,  101 
Middle  finger.     See  Finger,  middle, 
palmar  space.     See  Palmar  space, 
middle. 
Mi.xed  gaseous  gangrene,  388 
Mock,  Harry  E.,  365 

N 

Necrosis  of  bones  of  wrist,  421 

of  tendons,  199,  263 
Nerves  to  thenar  muscles,   relation  of, 

to  tendon  sheath,  262 
Nicaise,  231,  244 
Normal  salt  solution   in   lymphangitis, 

351 


Occup.\Tio.\.\L  therapy  in  restoration  of 

function,  489 
Oidiomycosis,  49 

diagnosis  of,  49 
Osteomyelitis,  426 

of  metacarpal  bones,  192 


F.VLM,  infections  beginning  in,  193 

lymphatics  of,  303 

relation  of,  to  infections,  313 

wound  of,  punctured,  193 
Palmar  abscess,  drainage  in,  278 


498 


INDEX 


Palmar  fascia,  relation  of,  to  abscesses, 
193 
sheath,  intermediary,  anterior,  108 

posterior,  108 
space,  middle,  90,  99 

abscess  of,   treatment  of, 

277 
anatomy  of,  88,  95 
boundaries,       diverticula, 
and  position  of  second- 
ary abscesses  in  case  of 
rupture  from,  141 
experimental     study      of 
boundaries 
and  position  of 
secondary   ab- 
scess in  case  of 
extension  from, 
126 
of  site  of  rupture 
and  extensions 
into     forearm, 
154 
infections  of,  after-results 
of,  198 
diagnosis  of,  215 
by    direct    implanta- 
tion, 165 
extension  from,  171 
to  thenar  space, 

175 
to    ulnar   bursae, 
177 
relation  of,  to  hypo- 
thenar  space,  175 
involved    from    infection 
spreading         from 
sides  of  fingers,  171 
secondary  to  fascial- 
space       infec- 
tion, 175 
to     little     finger 

infection,  209 
to     middle    and 
ring  finger  ten- 
osynovitis, 164 
189,  191,  209 
to  ring  finger  in- 
fection, 191 
to  tenosynovitis, 
treatment     of, 
251,  259 
involvement  of,  source  of, 

178 
and  subaponeurotic  spaces 
combined    involvement 
of,  treatment  of,  284 
and    thenar    space,     8"^" 
bined  involve- 
ment of,  treat- 
ment of,  280 
interrelation    of, 
96 


I  Parona,  239 
Paronychia,  Zi 

pathology  of,  34 
treatment  of,  35 
types  of,  2>i 
Peptonized  food  in  lymphangitis,  351 
Periglandular  abscess,  treatment  of,  356 
Phalanges,  distal,   25 

infection  of,  25 

involvement  of  joints  of,  treat- 
ment of,  248 
protractor  for  measuring  range  of 
motion  of,  485 
Phalanx,  435 

involved,  secondary  to  little  finger 

infection,  204 
middle,  211 
Phlegmon  of  dorsum,  treatment  of,  355 
Phlegmonous  lymphangitis,   328 
Poirier,  296 
Poulsen,  242 

Protractor     for     measuring     range     of 
motion     of     phal- 
anges, 485 
at  wrist-joint,  486 
Psychotherapy  in  restoration  of  func- 
tion, 492 
Punctured  wound  of  palm,  193 


Radial  artery,  abscesses  along,  171 
bursa,  102 

anatomy  peculiar  to  infections, 

404 
communication  of,  with  ulnar 

bursa,  107 
diagnosis   of   extensions   from 
infections  beginning  in,  213 
experimental  study  of  site  of 
rupture  and   extension  into 
forearm  from,  152 
infections  of,  extension  of,  to 
ulnar  bursa,  161 
treatment  of,  261 
involved    secondary    to    little 
finger  infection,  204, 
207 
to     tenosynovitis    of 
thumb,  213 
bursitis,  diagnosis  of,  213 
lymphatics,  abscesses  of,  170 
Restoration  of  function  of  hand,  474 
Rheumatism  of  wrist,  224 
Ring  finger.     See  Finger,  ring. 
Rubber  tubes  in  treatment  of  infections, 

77 
"Run-around"  paronychia,  ii 


Sacciform  lymphatic  dilatations,  297 
Safety  first,  365 


INDEX 


499 


Sappcy,  296 
Scheide,  234 
Schleich,  241 
Schullcr,  235,  244 
Septicemia,  2>ii 

Serum  and  vaccine  Irealmenl  in  lymph- 
angitis, 352 
Shirt-stud  abscess,  55 
Sinuses  in  chronic  processes,  446 

treatment  of,  445 
Splints,  use  of,  in  restoration  of  function, 

480 
Sporotrichosis,  317 
Staphylococcic  tenosynovitis,  203 
Streptococcic  tenosynovitis,  203 
Streptococcus  infections,  hemolysis  in, 

316 
Subaponeurotic  space,  abscess  of,  treat- 
ment of,  289 
boundaries,     diverticula,     and 
position    of    secondary    ab- 
scesses  in   case    of   rupture 
from,  141 
infection    from,    extension    of, 
177 
secondary  changes  follow- 
ing, 201 
source  of,  168,  177 
treatment  of,  284,  289 
Subcutaneous  abscess  following  radial 
bursal   inflammation,    treatment 
of,  261 
tenosynovitis,  treatment  of,  261 
tissue,  source  of  infection,  168 
Subepithelial  abscess,  39 
Symbiosis,  effect  of,  on  course  of  infec- 
tion, 311 
Synovial  sacs,  accessory,  107 

sheaths   of   dorsum,   infections   of, 
treatment  of,  271 
of   fascial  spaces  and  relation 

between,  113 
of  wrist-joint,  422 


Tendons,  necrosis  of,  197,  263 
treatment  of,  447 
prevention  of  adhesions  of,  in  teno- 
synovitis, 274 
prolapse  at  wrist,  prevented  after 

incision,   273 
sheaths,     anatomical     distribution 
and  relations  of,  100 
extension     to     fascial     spaces 
from,  164 
from  little  finger,  192 
of  extensor  carpi  radialis  long- 
ior  and  brevior,  110 
ulnaris,  112 
communis  digitorum,  112 
indicis,  112 
longus  pollicis,  111 


Tendon    sheaths    of     extensor     minimi 
digiti,  112 
ossis    mctacarpi    pollicis, 
110 
to  fascial  spaces,  relations  of, 

125 
of  flexor  longus  pollicis,  102 

experimental 
study  of  exten- 
sion after  rup- 
ture from,  124 
surface,  100 

tendon  of  little  finger,  164 
of   index   finger,   experimental 
study  of  extension  after  rup- 
ture from,  122 
intercommunication  of,  107 
of  little  finger,  103 

experimental      study 
of    extension    after 
rupture   from,    118 
.  of  middle,  finger,  experimental 
study  of  extension 
after  rupture  from, 
116 
infection      involving, 
189 
of    ring    finger,    experimental 
study  of  extension  after  rup- 
ture from,  117 
rupture  of,  relation  of,  to  fas- 
cial spaces,  117 
of  thumb,  anatomical  study  of 
relation    of,    to    motor 
nerves   of   thenar   mus- 
cles, 261 
removal  of,  263 
spread  of  infection  involv- 
ing, 188 
upon  dorsum,  110 
Tenosynovitis,  61 

acute    suppurative,    treatment   of, 

245 
adhesions  in,  203 

prevention  of,  274 
after-treatment  of,  272 

position  of  hand  in,  274 
by  aspiration,  diagnosis  of,  250 
diagnosis  of,  201 
drainage  in,  248,  272 
dressing  in,  dry,  273 

hot,  moist,  245,  273 
edema  in,  202 
etiology  of,  159 
extension  of,   from  one  sheath  to 

another,  161 
of  flexor  longus  pollicis,  213 

extension  from,  213 
following  lymphangitis,  treatment 

of,  353 
gonorrheal, '224 
incision  in,  248 
of  index  finger,  treatment  of,  248,250 


500 


INDEX 


Tenosynovitis,  invohcnient  of   \arious 
sheaths  in,  160 
of  Httle  finger,  treatment  of,  252 
lumbrical  space  and,  249 
of  middle  finger,  treatment  of,  248 
pathogenesis  of,  159 
pathology  of,  197 

preserving  function  of  joints  in,  274 
prognosis  of,  291 
relation  of,  to  lymphangitis,  295 
of  ring  finger,  treatment  of,  248 
staphylococcic,  203 
streptococcic,  203 
subcutaneous     abscess     following, 

treatment  of,  261 
surgical  considerations  of,  159 
symptoms  and  signs  of,  201 
tenderness  in,  202 
of  thumb,  treatment  of,  261 
treatment  of,  226,  261 

elevation  of  part  in,  248 
immobilization  in,  272 
passive  and  active  movements 

in,  274 
rest  in,   248 
Thenar    area,    involved    secondary    to 
index    tenosynovitis,    treatment 
of,  250 
space,  91 

abscess  of,  treatment  of,  287 
anatomy  of,  91,  96 
boundaries,     diverticula,     and 
position    of    secondary    ab- 
scesses   in    case    of    rupture 
from,  141 
experimental  study  of  bound- 
aries and  position  of  second- 
ary abscess  in  case  of  rup- 
ture from,  132 
infection  of,  diagnosis  of,  216 
extension    of,    to    middle 
palmar  space,  175 
to  other  spaces,  175 
from  tendon  sheath,  186 
involved   from   infection  from 
sides  of  fingers,  171 
from  metacarpo  phalangeal 

arthritis,  182 
from  middle  palmar  space, 

173 
secondary  to  index  finger 
tenosynovitis,  210 
to   tendon-sheath   in- 
fection, 165 
involvement  of,  source  of,  178 
middle    palmar    abscess    and, 
treatment  of,  287 
space  and,  inter-rela- 
tion of,  96 
Thiersch  graft  after  carbuncles,  48 
Thrombophlebitis,  339 
-Thumb,  infection  invplving,188 
tendon  sheath  of,  103 


Thumb,  tendon  sheaths  of,  extension  of 
rupture  from,  124 
tenosynovitis  of,  treatment  of,  261 

Tillaux,  235 

Tillmans,  208 

Toxic  gaseous  gangrene,  388 

Toxins,  virulent,  prevention  of  absorp- 
tion of,  250 

Transplantation  of  fat  in  contractures, 
461 

U 

Ulnar  artery,  abscesses  along,  171 
hemorrhage  and,  415 
bursa,  103 

communication  of,  with  radial 
bursa,  107 
with     tendon     sheath     of 
ring,  middle,  and  index 
finger,  108 
experimental  study  of  site  of 
rupture  and  extension  into 
forearm,  152 
extensions  from,  treatment  of, 

260 
infection  of,   extension   of,   to 
radial  bursa,  161 
incision  in,  254 
involved  from  middle  palmar 
space  infection,   177 
secondary'  to  little  finger 
infection,  204 
to  radial  bursal  infec- 
tion,   diagnosis   of, 
214 
tenosynovitis  of,  treatment  of, 
252 
sheath     infection,     secondary     to 
radial  bursal  inflammation,  treat- 
ment of,  263 


V'ON  VoLKMAXN  treatment  of  tenosyno- 
vitis, 234 

W 

Web  of  finger,  infection  from,  191 

involved,  secondary  to  tenosynovi- 
tis, treatment  of,  251 
si)ace,  99 
Wound  of  palm,  punctured,  193 
Wrist  rheumatism,  224 
Wrist-joint,  bones  of,  necrosis  of,  421 
infection  of,  preservation  of  func- 
tion in,  421 
secondary   to   little   finger   in- 
volvement,  204 
involvement  of,  403 

treatment  of,  421 
protractor  for  measuring  range  of 
I  motion  at,  486  y 

'  resection  of,  436  / 


.«-> 


Date  Due 


M 


IM^.^- 


